MEDICARE: HEARTLAND CLINIC

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	104100000X	Social Worker	33005046A	IN

General Provider Information

NPI Number	:	1790849610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEARTLAND CLINIC

Provider Business Mailing Address
First Line	:	2201 FERRY ST
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47904-3047
Country	:	US
Telephone Number	:	765-446-9898
Fax Number	:

Provider Business Practice Location Address
First Line	:	2201 FERRY ST
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47904-3047
Country	:	US
Telephone Number	:	765-446-9898
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	MR. SUSANNAH LEIGH DEVAULT
Credential	:	MSW, LSW
Telephone Number	:	765-446-9898

Provider Enumeration Date	:	12/22/2006
Last Update Date	:	08/22/2020

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Directions to “HEARTLAND CLINIC ” Practice Location

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