MEDICARE: DESADAREA D ZYLSTRA MA, LMHCA, NCC

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	88000744A	IN

General Provider Information

NPI Number	:	1770194227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESADAREA D ZYLSTRA MA, LMHCA, NCC

Provider Business Mailing Address
First Line	:	2736 WINCHESTER DR APT B
Second Line	:
City	:	VALPARAISO
State	:	IN
Zip	:	46383-2810
Country	:	US
Telephone Number	:	219-508-7577
Fax Number	:

Provider Business Practice Location Address
First Line	:	2801 BERTHOLET BLVD STE 301
Second Line	:
City	:	VALPARAISO
State	:	IN
Zip	:	46383-7959
Country	:	US
Telephone Number	:	708-820-8097
Fax Number	:

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

Provider Enumeration Date	:	08/10/2020
Last Update Date	:	08/10/2020

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