Provider Demographics
NPI:1225228828
Name:PRIMUS, SALLY ANN (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:PRIMUS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3176 LANCER ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368
Mailing Address - Country:US
Mailing Address - Phone:219-762-9557
Mailing Address - Fax:219-762-7318
Practice Address - Street 1:3176 LANCER ST
Practice Address - Street 2:SUITE 501
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368
Practice Address - Country:US
Practice Address - Phone:219-762-9557
Practice Address - Fax:219-762-7318
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99027928A1041C0700X
IN34006144A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10016380AMedicaid
IN485380Medicare PIN