Healthcare Provider Details

I. General information

NPI: 1508495086
Provider Name (Legal Business Name): STEPHANIE KANDRAC BEWLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 E 82ND ST
INDIANAPOLIS IN
46240-2211
US

IV. Provider business mailing address

557 E 82ND ST
INDIANAPOLIS IN
46240-2211
US

V. Phone/Fax

Practice location:
  • Phone: 317-441-5984
  • Fax:
Mailing address:
  • Phone: 317-441-5984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34008755A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: