MEDICARE: BRIDGETTE LEORA SPANN EDWARDS LCSW, LCAC

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	101Y00000X	Counselor
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	87000232A	IN
3	1041C0700X	Clinical Social Worker	34008190A	IN

General Provider Information

NPI Number	:	1174667745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIDGETTE LEORA SPANN EDWARDS LCSW, LCAC

Provider Business Mailing Address
First Line	:	4830 MCCOOK AVE
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-3552
Country	:	US
Telephone Number	:	219-398-9715
Fax Number	:

Provider Business Practice Location Address
First Line	:	4818 INDIANAPOLIS BLVD
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-3433
Country	:	US
Telephone Number	:	219-397-5117
Fax Number	:	219-397-4737

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

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	11/02/2018

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