Healthcare Provider Details

I. General information

NPI: 1124013933
Provider Name (Legal Business Name): JOSEPH E CHAMBERLAIN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 JOLIET ST
DYER IN
46311-1705
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-322-5747
  • Fax: 219-864-2282
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34001010A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier90000854
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBCBSIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: