Healthcare Provider Details

I. General information

NPI: 1477584571
Provider Name (Legal Business Name): CARLOS BECERRA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9405 E COUNTY ROAD 400 N
BROWNSBURG IN
46112-8919
US

IV. Provider business mailing address

1481 W 10TH ST
INDIANAPOLIS IN
46202-2803
US

V. Phone/Fax

Practice location:
  • Phone: 317-852-4089
  • Fax:
Mailing address:
  • Phone: 317-988-3027
  • Fax: 317-988-3312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34000510A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: