Healthcare Provider Details

I. General information

NPI: 1346647583
Provider Name (Legal Business Name): PATRICIA BAILEY-JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 03/13/2021
Certification Date: 03/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 JOLIET ST
DYER IN
46311-1705
US

IV. Provider business mailing address

1040 SIERRA DR STE 400
GREENWOOD IN
46143-7241
US

V. Phone/Fax

Practice location:
  • Phone: 244-631-1170
  • Fax:
Mailing address:
  • Phone: 317-528-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34007005A
License Number StateIN

VII. Legacy identifiers

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

# 1
IdentifierM47140441
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerMEDICARE
# 2
Identifier300041505
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: