Provider Demographics
NPI:1164169611
Name:HENDRICKS, ELISHIA MARIE (LSW)
Entity Type:Individual
Prefix:
First Name:ELISHIA
Middle Name:MARIE
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 E 3RD ST # 1024
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5434
Mailing Address - Country:US
Mailing Address - Phone:812-341-6961
Mailing Address - Fax:
Practice Address - Street 1:2801 BERTHOLET BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383
Practice Address - Country:US
Practice Address - Phone:812-341-6961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33010826A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker