Provider Demographics
NPI:1497236442
Name:IMBER, KATRINA LOUISE (LSW)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:LOUISE
Last Name:IMBER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5407
Mailing Address - Country:US
Mailing Address - Phone:260-484-4153
Mailing Address - Fax:
Practice Address - Street 1:2525 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5407
Practice Address - Country:US
Practice Address - Phone:260-715-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200340250Medicaid