Provider Demographics
NPI:1548399900
Name:NISWANDER, NATALIE ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:ANN
Last Name:NISWANDER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5554
Mailing Address - Country:US
Mailing Address - Phone:260-422-1680
Mailing Address - Fax:260-422-1555
Practice Address - Street 1:3737 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5554
Practice Address - Country:US
Practice Address - Phone:260-422-1680
Practice Address - Fax:260-422-1555
Is Sole Proprietor?:No
Enumeration Date:2007-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002087A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN209380CMedicare ID - Type UnspecifiedINDIVIDUAL PROVIDER