Healthcare Provider Details

I. General information

NPI: 1316228000
Provider Name (Legal Business Name): ROBERTO MIGUEL MAGALLANEZ LCSW, LCAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3310 E 10TH ST # 4-156
JEFFERSONVILLE IN
47130-7285
US

IV. Provider business mailing address

3310 E 10TH ST # 4-156
JEFFERSONVILLE IN
47130-7285
US

V. Phone/Fax

Practice location:
  • Phone: 812-624-1180
  • Fax:
Mailing address:
  • Phone: 812-624-1180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5074
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34007166A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number34007166A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: