Healthcare Provider Details

I. General information

NPI: 1730188798
Provider Name (Legal Business Name): CHRISTINE ANN MOTHERWELL MSW, LMHC, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 GOSHEN RD 260
FORT WAYNE IN
46808-1493
US

IV. Provider business mailing address

2422 PRESTON DR
FORT WAYNE IN
46815-6852
US

V. Phone/Fax

Practice location:
  • Phone: 260-471-3500
  • Fax: 260-471-4263
Mailing address:
  • Phone: 260-602-5612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34004390A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: