Healthcare Provider Details

I. General information

NPI: 1427129923
Provider Name (Legal Business Name): LAILA PEDERSEN FINGERHUT LCSW LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17917 KILLINGTON WAY
SOUTH BEND IN
46614-9773
US

IV. Provider business mailing address

17917 KILLINGTON DR
SOUTH BEND IN
46614-9773
US

V. Phone/Fax

Practice location:
  • Phone: 574-291-2645
  • Fax: 574-291-3700
Mailing address:
  • Phone: 574-291-2645
  • Fax: 574-291-3700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34002895A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001428A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: