Healthcare Provider Details

I. General information

NPI: 1528041308
Provider Name (Legal Business Name): MICHELLE LYNN MCBRAYER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6050 STERLING CREEK RD
PORTAGE IN
46368-7752
US

IV. Provider business mailing address

PO BOX 1430
PORTAGE IN
46368-9230
US

V. Phone/Fax

Practice location:
  • Phone: 219-763-8112
  • Fax: 219-764-5380
Mailing address:
  • Phone: 219-763-8112
  • Fax: 219-764-5380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34003798A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: