MEDICARE: DEAN ULLRICH MSW

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	34000828A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	039365	OTHER	IN	VALUEOPTIONS
2	0007668135	OTHER	IN	AETNA PIN
3	000000176433	OTHER	IN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1538210166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEAN ULLRICH MSW

Provider Business Mailing Address
First Line	:	3174 MALLARD COVE LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2882
Country	:	US
Telephone Number	:	260-432-7510
Fax Number	:	260-432-8512

Provider Business Practice Location Address
First Line	:	3174 MALLARD COVE LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2882
Country	:	US
Telephone Number	:	260-432-7510
Fax Number	:	260-432-8512

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

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	12/30/2011

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Directions to “ DEAN ULLRICH MSW” Practice Location

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