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General NPI Number Information
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NPI Number | 1487951893
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Entity Type | Individual
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Provider Name | ANGELA BEANBLOSSOM LCSW
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Gender | Female
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Dates
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Enumeration Date | 02/21/2011
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Last Update Date | 02/21/2011
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Provider Practice Location Address
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Address Line | 289 IRELAND AVE MEDDAC BLDG 851 RM 9-40
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City | FORT KNOX
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State | KY
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Zip | 40121-5111
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Country | US
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Telephone | 502-624-9006
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Fax |
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Provider Business Mailing Address
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Address Line | 4329 W MOUNT CARMEL RD
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City | SALEM
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State | IN
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Zip | 47167-8258
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Country | US
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Telephone | 812-472-3710
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 34004306A
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License Number State | IN
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