Healthcare Provider Details

I. General information

NPI: 1215530100
Provider Name (Legal Business Name): RACHAEL BETH WALDMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2020
Last Update Date: 11/21/2020
Certification Date: 11/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 FLAGSTONE DR
DYER IN
46311-2290
US

IV. Provider business mailing address

1212 FLAGSTONE DR
DYER IN
46311-2290
US

V. Phone/Fax

Practice location:
  • Phone: 847-875-8097
  • Fax:
Mailing address:
  • Phone: 847-875-8097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34009039A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149022703
License Number StateIL

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: