Healthcare Provider Details

I. General information

NPI: 1386946937
Provider Name (Legal Business Name): ALEX JAI MADERAS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 10/02/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAMPAGNA ACADEMY 7403 CLINE AVENUE
SCHEREVILLE IN
46375
US

IV. Provider business mailing address

GIBAULT CARE INC 6401 S. US HWY 41
TERRE HAUTE IN
47802-4749
US

V. Phone/Fax

Practice location:
  • Phone: 219-322-8614
  • Fax:
Mailing address:
  • Phone: 812-299-1156
  • Fax: 812-298-3109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33005858A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34006800A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: