Healthcare Provider Details

I. General information

NPI: 1285871673
Provider Name (Legal Business Name): TIMOTHY D GEARHART LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 S 25 W
WINAMAC IN
46996-8338
US

IV. Provider business mailing address

840 S 25 W STE A
WINAMAC IN
46996-8338
US

V. Phone/Fax

Practice location:
  • Phone: 574-242-0094
  • Fax:
Mailing address:
  • Phone: 574-242-0094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34005777A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: