Healthcare Provider Details

I. General information

NPI: 1265566897
Provider Name (Legal Business Name): GLORIA JEAN VERBANAC LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N RITTER AVE
INDIANAPOLIS IN
46219-3027
US

IV. Provider business mailing address

6626 E 75TH STREET STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-355-2560
  • Fax:
Mailing address:
  • Phone: 317-621-7561
  • Fax: 317-355-6096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number34004791A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: