Provider Demographics
NPI:1376735084
Name:LENGERICH, MANDY LYNN (MSW)
Entity type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:LYNN
Last Name:LENGERICH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MISS
Other - First Name:MANDY
Other - Middle Name:LYNN
Other - Last Name:KRUECKEBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:10315 DAWSONS CREEK BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1912
Mailing Address - Country:US
Mailing Address - Phone:260-387-6340
Mailing Address - Fax:
Practice Address - Street 1:10315 DAWSONS CREEK BLVD STE E
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1912
Practice Address - Country:US
Practice Address - Phone:260-387-6340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INN/A104100000X
1041C0700X
IN34006139A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker