MEDICARE: CHRISTINE AHL DURBIN L.C.S.W

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	34000701	IN

General Provider Information

NPI Number	:	1376608026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE AHL DURBIN L.C.S.W

Provider Business Mailing Address
First Line	:	148 SAGAMORE PKWY W
Second Line	:
City	:	WEST LAFAYETTE BRA
State	:	IN
Zip	:	47906-1569
Country	:	US
Telephone Number	:	765-463-3016
Fax Number	:	765-463-2710

Provider Business Practice Location Address
First Line	:	148 SAGAMORE PKWY W
Second Line	:
City	:	WEST LAFAYETTE BRA
State	:	IN
Zip	:	47906-1569
Country	:	US
Telephone Number	:	765-463-3016
Fax Number	:	765-463-2710

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

Provider Enumeration Date	:	12/23/2006
Last Update Date	:	07/08/2007

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