=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134261928
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA DENISE LEEMASTER LCSW, ACSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 12/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4004 CAMPBELL
-----------------------------------------------------
City | VALPARAISO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-462-9000
-----------------------------------------------------
Fax | 219-462-9000
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 815 MAIN ST. SUITE 1D
-----------------------------------------------------
City | ST. JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-982-4055
-----------------------------------------------------
Fax | 219-462-9000
-----------------------------------------------------
=====================================================
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 | 34003981A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801090052
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------