Healthcare Provider Details

I. General information

NPI: 1548385669
Provider Name (Legal Business Name): VALERIE D WISE BURRELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9245 CALUMET AVE SUITE 101-A
MUNSTER IN
46321-2821
US

IV. Provider business mailing address

9245 CALUMET AVE SUITE 101-A
MUNSTER IN
46321-2821
US

V. Phone/Fax

Practice location:
  • Phone: 708-269-8063
  • Fax: 219-810-6459
Mailing address:
  • Phone: 708-269-8063
  • Fax: 219-810-6459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34006621A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149008210
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: