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NPI Code Detail

MEDICARE: BRET DAVIS EARTHEART MSW, LCSW

MEDICARE: BRET DAVIS EARTHEART MSW, LCSW
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
11041C0700XClinical Social Worker34006996AIN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1000000991115OTHERINANTHEM
25338998OTHERAETNA

General Provider Information

NPI Number : 1760788913
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRET DAVIS EARTHEART MSW, LCSW
Provider Business Mailing Address
First Line : 4307 S LEONARD SPRINGS RD
Second Line :
City : BLOOMINGTON
State : IN
Zip : 47403-4078
Country : US
Telephone Number : 812-345-2176
Fax Number : 206-984-2440
Provider Business Practice Location Address
First Line : 4307 S LEONARD SPRINGS RD
Second Line :
City : BLOOMINGTON
State : IN
Zip : 47403-4078
Country : US
Telephone Number : 812-345-2176
Fax Number : 206-984-2440
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/07/2011
Last Update Date : 11/29/2018

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