Healthcare Provider Details

I. General information

NPI: 1225281728
Provider Name (Legal Business Name): ELIZABETH ANNE TEMPLE MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W 4TH ST SUITE 100-A
MISHAWAKA IN
46544-1948
US

IV. Provider business mailing address

PO BOX 6489
SOUTH BEND IN
46660-6489
US

V. Phone/Fax

Practice location:
  • Phone: 574-252-0369
  • Fax: 574-252-3694
Mailing address:
  • Phone: 574-472-6700
  • Fax: 574-472-6746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number34004291A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34004291A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: