Provider Demographics
NPI:1760565055
Name:BEATHEA, CAROL JOANN (PHD LCSW MSW)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:JOANN
Last Name:BEATHEA
Suffix:
Gender:F
Credentials:PHD LCSW MSW
Other - Prefix:
Other - First Name:C
Other - Middle Name:JOANN
Other - Last Name:BEATHEA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD MSW LCSW
Mailing Address - Street 1:330 W LEXINGTON AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516
Mailing Address - Country:US
Mailing Address - Phone:574-293-5991
Mailing Address - Fax:574-293-5429
Practice Address - Street 1:330 W LEXINGTON AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516
Practice Address - Country:US
Practice Address - Phone:574-293-5991
Practice Address - Fax:574-293-5429
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000509A104100000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000183551OtherBCBS ANTHEM
IN179650AMedicare ID - Type Unspecified