MEDICARE: SUPPORTIVE SOCIAL WORK SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1003797119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPPORTIVE SOCIAL WORK SERVICES LLC

Provider Business Mailing Address
First Line	:	904 BECKER ST
Second Line	:
City	:	HAMMOND
State	:	IN
Zip	:	46320-2109
Country	:	US
Telephone Number	:	219-677-3169
Fax Number	:

Provider Business Practice Location Address
First Line	:	9501 INDIANAPOLIS BLVD STE A
Second Line	:
City	:	HIGHLAND
State	:	IN
Zip	:	46322-2665
Country	:	US
Telephone Number	:	219-368-1545
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	MS. TENISHA FENNIE
Credential	:	LCSW
Telephone Number	:	219-677-3169

Provider Enumeration Date	:	09/08/2025
Last Update Date	:	09/08/2025

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