Provider Demographics
NPI:1699829648
Name:LICHTSINN, HOLLY R (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:R
Last Name:LICHTSINN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:FRIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:10319 DAWSONS CREEK BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1911
Mailing Address - Country:US
Mailing Address - Phone:260-969-5583
Mailing Address - Fax:260-969-5584
Practice Address - Street 1:10319 DAWSONS CREEK BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1911
Practice Address - Country:US
Practice Address - Phone:260-969-5583
Practice Address - Fax:260-969-5584
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100124250Medicaid