Healthcare Provider Details

I. General information

NPI: 1912922550
Provider Name (Legal Business Name): GLOBE STAR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 BROADWAY
CHESTERTON IN
46304-2259
US

IV. Provider business mailing address

621 BROADWAY
CHESTERTON IN
46304-2259
US

V. Phone/Fax

Practice location:
  • Phone: 219-921-5492
  • Fax: 219-921-0143
Mailing address:
  • Phone: 219-921-5492
  • Fax: 219-921-0143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number100110700
License Number StateIN

VIII. Authorized Official

Name: DR. ANTHONY MICHAEL MCCROVITZ
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 219-921-5492