=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992304059
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER B QUALY MS, LCSW, LCAC, LMFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2020
-----------------------------------------------------
Last Update Date | 10/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6552 LANA CT E
-----------------------------------------------------
City | NEW PALESTINE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46163-9777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-440-8380
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6552 LANA CT E
-----------------------------------------------------
City | NEW PALESTINE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46163-9777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 131-744-0838
-----------------------------------------------------
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 | 34002808A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------