MEDICARE: MISTY BLANN ASW

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	0904008819	VA
2	1041C0700X	Clinical Social Worker	34007530A	IN

General Provider Information

NPI Number	:	1336492826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY BLANN ASW

Provider Business Mailing Address
First Line	:	1813 WILLOW ST STE 6A
Second Line	:
City	:	VINCENNES
State	:	IN
Zip	:	47591-4279
Country	:	US
Telephone Number	:	812-882-0894
Fax Number	:

Provider Business Practice Location Address
First Line	:	1813 WILLOW ST STE 6A
Second Line	:
City	:	VINCENNES
State	:	IN
Zip	:	47591-4279
Country	:	US
Telephone Number	:	812-882-0894
Fax Number	:

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

Provider Enumeration Date	:	10/21/2012
Last Update Date	:	07/05/2018

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