Provider Demographics
NPI:1457495418
Name:LICHTSINN, CHANDA (SLP)
Entity Type:Individual
Prefix:
First Name:CHANDA
Middle Name:
Last Name:LICHTSINN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3703 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-2301
Mailing Address - Country:US
Mailing Address - Phone:260-456-4988
Mailing Address - Fax:
Practice Address - Street 1:2626 SAINT JOE CENTER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5042
Practice Address - Country:US
Practice Address - Phone:260-497-0328
Practice Address - Fax:260-497-0904
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003366A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200621390OtherFIRST STEPS
IN200324980Medicaid