Provider Demographics
NPI:1619399557
Name:LUALLEN, MICHELLE (LCSW,LCAC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LUALLEN
Suffix:
Gender:F
Credentials:LCSW,LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 E ARCH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3461
Mailing Address - Country:US
Mailing Address - Phone:317-294-7100
Mailing Address - Fax:
Practice Address - Street 1:912 N DELAWARE ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3348
Practice Address - Country:US
Practice Address - Phone:217-660-2848
Practice Address - Fax:317-660-2848
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-13
Last Update Date:2018-03-17
Deactivation Date:2016-04-04
Deactivation Code:
Reactivation Date:2017-07-20
Provider Licenses
StateLicense IDTaxonomies
IN340058041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12626384OtherCAQH
IN34005804AOtherPROFESSIONAL LICENSE