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General NPI Number Information
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NPI Number | 1619432119
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Entity Type | Organization
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Legal Business Name | LIFE AND TRAUMA SURVIVOR CENTER LLC
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Dates
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Enumeration Date | 02/08/2019
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Last Update Date | 11/04/2024
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Provider Practice Location Address
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Address Line | 402 WALL ST STE 42
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City | VALPARAISO
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State | IN
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Zip | 46383-2572
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Country | US
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Telephone | 219-510-8043
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Fax | 219-241-8044
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Provider Business Mailing Address
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Address Line | 402 WALL ST STE 42
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City | VALPARAISO
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State | IN
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Zip | 46383-2572
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Country | US
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Telephone | 219-510-8043
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Fax | 219-510-8044
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Authorized Official
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Title or Position | OWNER
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Name | SHERRIE ANN SHIVOK
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Credential | LMHC
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Telephone | 219-241-0212
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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