Healthcare Provider Details

I. General information

NPI: 1073550364
Provider Name (Legal Business Name): CHRISTA RUGH DETZEL L.C.S.W., L.M.F.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 S LYNHURST DR
INDIANAPOLIS IN
46241-5100
US

IV. Provider business mailing address

282 LANSDOWNE RD
INDIANAPOLIS IN
46234-2507
US

V. Phone/Fax

Practice location:
  • Phone: 317-247-8918
  • Fax: 317-381-0619
Mailing address:
  • Phone: 317-271-7468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34002670A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001105A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: