Provider Demographics
NPI:1265476949
Name:QUEDENFELD, CARL DIXON (LMHC,LCSW)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:DIXON
Last Name:QUEDENFELD
Suffix:
Gender:M
Credentials:LMHC,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8320 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:INDPLS
Mailing Address - State:IN
Mailing Address - Zip Code:46227
Mailing Address - Country:US
Mailing Address - Phone:317-882-5122
Mailing Address - Fax:317-888-8642
Practice Address - Street 1:7930 VALLEY TRACE LANE
Practice Address - Street 2:
Practice Address - City:INDPLS
Practice Address - State:IN
Practice Address - Zip Code:46237
Practice Address - Country:US
Practice Address - Phone:317-294-6216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002578A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100323760AMedicaid
IN100323760AMedicaid