Provider Demographics
NPI:1396220703
Name:UTTERBACK, ELIZABETH MICHELLE (LCAC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MICHELLE
Last Name:UTTERBACK
Suffix:
Gender:F
Credentials:LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4618 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46218-2305
Mailing Address - Country:US
Mailing Address - Phone:317-435-7619
Mailing Address - Fax:
Practice Address - Street 1:4633 W RICHLAND PLAZA DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-9776
Practice Address - Country:US
Practice Address - Phone:812-287-9823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87000915101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)