Provider Demographics
NPI:1578628913
Name:MCARDLE-BIR, MARY M (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:M
Last Name:MCARDLE-BIR
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 1:4656 W JEFFERSON BLVD
Mailing Address - Street 2:285
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6857
Mailing Address - Country:US
Mailing Address - Phone:260-422-9372
Mailing Address - Fax:260-422-0843
Practice Address - Street 1:4656 W JEFFERSON BLVD
Practice Address - Street 2:285
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6857
Practice Address - Country:US
Practice Address - Phone:260-422-9372
Practice Address - Fax:260-422-0843
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002936A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN35001048AOtherLMFT
IN34002936AOtherLCSW
IN201530Medicare ID - Type Unspecified