Healthcare Provider Details

I. General information

NPI: 1386766160
Provider Name (Legal Business Name): WOUTERA NIJDAM MSW, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N JORDAN AVE
BLOOMINGTON IN
47405-3190
US

IV. Provider business mailing address

2712 BRIGS BND
BLOOMINGTON IN
47401-4402
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-8447
  • Fax:
Mailing address:
  • Phone: 812-333-8751
  • Fax: 812-333-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33004946A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: