Healthcare Provider Details

I. General information

NPI: 1326285495
Provider Name (Legal Business Name): MIDWEST INSTITUTE OF TRAINING AND DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 01/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W WASHINGTON ST STE 1910
SOUTH BEND IN
46601-1711
US

IV. Provider business mailing address

211 W WASHINGTON ST STE 1910
SOUTH BEND IN
46601-1711
US

V. Phone/Fax

Practice location:
  • Phone: 574-292-6553
  • Fax: 574-232-0124
Mailing address:
  • Phone: 574-292-6553
  • Fax: 574-232-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34000195A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35000665A
License Number StateIN

VIII. Authorized Official

Name: MS. KAY A GRASK
Title or Position: VP
Credential: LCSW, LMFT
Phone: 574-292-6553