Healthcare Provider Details

I. General information

NPI: 1235286352
Provider Name (Legal Business Name): MARY JANE VACHON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY JANE MURRAY VACHON LCSW

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N MICHIGAN ST BOX 42
SOUTH BEND IN
46601-1295
US

IV. Provider business mailing address

300 N MICHIGAN ST BOX 42
SOUTH BEND IN
46601-1295
US

V. Phone/Fax

Practice location:
  • Phone: 574-287-7399
  • Fax:
Mailing address:
  • Phone: 574-287-7399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number34002602A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: