Healthcare Provider Details

I. General information

NPI: 1639433345
Provider Name (Legal Business Name): VIVIAN LYNNE IRETON LCSW, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5048 S PLAZA DR
NEWBURGH IN
47630-3069
US

IV. Provider business mailing address

1100 ERIE AVE UNIT 705
EVANSVILLE IN
47715-4858
US

V. Phone/Fax

Practice location:
  • Phone: 812-449-9355
  • Fax:
Mailing address:
  • Phone: 812-449-9355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number86000183A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34006251A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: