Healthcare Provider Details

I. General information

NPI: 1912696451
Provider Name (Legal Business Name): TRACEY MALESA-WHEATON, LCSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 W LASALLE AVE APT 2
SOUTH BEND IN
46601-1166
US

IV. Provider business mailing address

429 W LASALLE AVE APT 2
SOUTH BEND IN
46601-1166
US

V. Phone/Fax

Practice location:
  • Phone: 574-520-8444
  • Fax: 574-367-2154
Mailing address:
  • Phone: 574-520-8444
  • Fax: 574-367-2154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TRACEY MALESA-WHEATON
Title or Position: OWNER
Credential:
Phone: 574-520-4444