Healthcare Provider Details

I. General information

NPI: 1770238545
Provider Name (Legal Business Name): CHARLA JOYCE CANNON YEARWOOD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2022
Last Update Date: 02/19/2022
Certification Date: 02/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9165 OTIS AVE STE 109
INDIANAPOLIS IN
46216-2307
US

IV. Provider business mailing address

9165 OTIS AVE STE 109
INDIANAPOLIS IN
46216-2307
US

V. Phone/Fax

Practice location:
  • Phone: 317-207-0380
  • Fax:
Mailing address:
  • Phone: 317-402-1604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number33006911A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: