MEDICARE: CHRIS DIEDERICH 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
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	39000598A	IN
2	1041C0700X	Clinical Social Worker	34004362A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000390191	OTHER	IN	ANTHEM BCBS PROVIDER PIN

General Provider Information

NPI Number	:	1821016700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRIS DIEDERICH LCSW

Provider Business Mailing Address
First Line	:	6626 E 75TH STREET
Second Line	:	STE 500
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-2890
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2040 N SHADELAND AVE
Second Line	:	STE 250
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-1711
Country	:	US
Telephone Number	:	317-355-5009
Fax Number	:

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

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	04/12/2018

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