Provider Demographics
NPI:1508507302
Name:BLAGOJEVIC, DEREK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:BLAGOJEVIC
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13820 MORSE ST
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-9645
Mailing Address - Country:US
Mailing Address - Phone:219-695-1144
Mailing Address - Fax:
Practice Address - Street 1:13820 MORSE ST
Practice Address - Street 2:
Practice Address - City:CEDAR LAKE
Practice Address - State:IN
Practice Address - Zip Code:46303-9645
Practice Address - Country:US
Practice Address - Phone:219-695-1144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33010576A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty