Provider Demographics
NPI:1225469877
Name:STOVER, BERTHOLD E (LCSW)
Entity Type:Individual
Prefix:
First Name:BERTHOLD
Middle Name:E
Last Name:STOVER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 HARTFORD ST.
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2138
Mailing Address - Country:US
Mailing Address - Phone:765-742-1567
Mailing Address - Fax:765-429-2700
Practice Address - Street 1:1716 HARTFORD ST.
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2138
Practice Address - Country:US
Practice Address - Phone:765-742-1567
Practice Address - Fax:765-429-2700
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34007054A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical