=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093074841
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LACONYEA DYLANA PITTS-THOMAS MSW, LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2012
-----------------------------------------------------
Last Update Date | 05/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 322 W 55TH AVE
-----------------------------------------------------
City | MERRILLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46410-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-985-8695
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 322 W 55TH AVE
-----------------------------------------------------
City | MERRILLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46410-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-985-8695
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 34006504A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------