Healthcare Provider Details

I. General information

NPI: 1639640824
Provider Name (Legal Business Name): ALISA ANN DAMHOLT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S 4TH ST
RICHMOND IN
47374-5407
US

IV. Provider business mailing address

301 S 4TH ST
RICHMOND IN
47374-5407
US

V. Phone/Fax

Practice location:
  • Phone: 505-414-8665
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34010704A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: