MEDICARE: MRS. CHRISTA RUGH DETZEL L.C.S.W., L.M.F.T.

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	1041C0700X	Clinical Social Worker	34002670A	IN
2	106H00000X	Marriage & Family Therapist	35001105A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000385233	OTHER	IN	ANTHEM BCBS PROVIDER PIN

General Provider Information

NPI Number	:	1073550364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHRISTA RUGH DETZEL L.C.S.W., L.M.F.T.

Provider Business Mailing Address
First Line	:	282 LANSDOWNE RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46234-2507
Country	:	US
Telephone Number	:	317-271-7468
Fax Number	:

Provider Business Practice Location Address
First Line	:	2345 S LYNHURST DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46241-5100
Country	:	US
Telephone Number	:	317-247-8918
Fax Number	:	317-381-0619

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	07/18/2007

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