Healthcare Provider Details

I. General information

NPI: 1811432396
Provider Name (Legal Business Name): GRACE LIEGIBEL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2016
Last Update Date: 12/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 N RITTER AVE
INDIANAPOLIS IN
46219-3026
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2805
US

V. Phone/Fax

Practice location:
  • Phone: 317-359-5467
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34007690A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: