MEDICARE: DEIDRA STOREY LSW, LMHC

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	101YM0800X	Mental Health Counselor	452541282	IN

General Provider Information

NPI Number	:	1558706408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIDRA STOREY LSW, LMHC

Provider Business Mailing Address
First Line	:	315 W LINCOLN RD
Second Line	:
City	:	KOKOMO
State	:	IN
Zip	:	46902-3850
Country	:	US
Telephone Number	:	765-450-4843
Fax Number	:

Provider Business Practice Location Address
First Line	:	941 E 86TH ST STE 120
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1842
Country	:	US
Telephone Number	:	812-631-0056
Fax Number	:

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

Provider Enumeration Date	:	05/06/2013
Last Update Date	:	01/16/2024

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