Healthcare Provider Details

I. General information

NPI: 1922113919
Provider Name (Legal Business Name): SUSAN DIANE ANDERSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 PINE LAKE AVE
LA PORTE IN
46350-3061
US

IV. Provider business mailing address

PO BOX 668
LA PORTE IN
46352-0668
US

V. Phone/Fax

Practice location:
  • Phone: 219-324-6263
  • Fax:
Mailing address:
  • Phone: 219-324-6263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34000100
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number34000100
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: