Provider Demographics
NPI:1073550364
Name:DETZEL, CHRISTA RUGH (LCSW, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTA
Middle Name:RUGH
Last Name:DETZEL
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 LANSDOWNE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46234-2507
Mailing Address - Country:US
Mailing Address - Phone:317-271-7468
Mailing Address - Fax:
Practice Address - Street 1:2345 S LYNHURST DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-5100
Practice Address - Country:US
Practice Address - Phone:317-247-8918
Practice Address - Fax:317-381-0619
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002670A1041C0700X
IN35001105A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000385233OtherANTHEM BCBS PROVIDER PIN
IN344840DDDDMedicare PIN