MEDICARE: MS. PATRICIA JUAN HOUSE 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	1041C0700X	Clinical Social Worker	34001701A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34001701A	OTHER	IN	STATE LICENSE NO
2	000000221076	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1932219862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PATRICIA JUAN HOUSE LCSW

Provider Business Mailing Address
First Line	:	PO BOX 88824
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46208-0824
Country	:	US
Telephone Number	:	317-372-1015
Fax Number	:	317-253-7388

Provider Business Practice Location Address
First Line	:	1104 E 35TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-3601
Country	:	US
Telephone Number	:	317-372-1015
Fax Number	:	317-253-7388

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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