=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811988132
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BAMBI L MEYER LCSW, MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2005
-----------------------------------------------------
Last Update Date | 06/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 436 E WASHINGTON BLVD
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46802-3210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-209-7111
-----------------------------------------------------
Fax | 260-222-2835
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 W MONROE ST STE 1200
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60603-2420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-733-9730
-----------------------------------------------------
Fax | 773-866-8014
-----------------------------------------------------
=====================================================
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 | 34005138A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------