Healthcare Provider Details

I. General information

NPI: 1700172830
Provider Name (Legal Business Name): KELLY P MUCHA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 04/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 US HIGHWAY 41
SCHERERVILLE IN
46375-1361
US

IV. Provider business mailing address

4524 WHITCOMB ST
GARY IN
46408-3506
US

V. Phone/Fax

Practice location:
  • Phone: 219-613-0332
  • Fax:
Mailing address:
  • Phone: 219-613-0332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: