Healthcare Provider Details

I. General information

NPI: 1619432119
Provider Name (Legal Business Name): LIFE AND TRAUMA SURVIVOR CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 WALL ST STE 42
VALPARAISO IN
46383-2572
US

IV. Provider business mailing address

402 WALL ST STE 42
VALPARAISO IN
46383-2572
US

V. Phone/Fax

Practice location:
  • Phone: 219-510-8043
  • Fax: 219-241-8044
Mailing address:
  • Phone: 219-510-8043
  • Fax: 219-510-8044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SHERRIE ANN SHIVOK
Title or Position: OWNER
Credential: LMHC
Phone: 219-241-0212