Provider Demographics
NPI:1508054008
Name:RATHBURN, LIZABETH A (LSW)
Entity Type:Individual
Prefix:
First Name:LIZABETH
Middle Name:A
Last Name:RATHBURN
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:2050 N MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-2048
Practice Address - Country:US
Practice Address - Phone:219-662-3300
Practice Address - Fax:219-662-3300
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33005130A104100000X
IN34006070A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200275200AMedicaid
IN200880ZMedicare PIN