Provider Demographics
NPI:1881624310
Name:DEICHMAN, ETHEL K (ACSW, LCSW)
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:K
Last Name:DEICHMAN
Suffix:
Gender:F
Credentials:ACSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1526
Mailing Address - Country:US
Mailing Address - Phone:574-722-5151
Mailing Address - Fax:574-739-1414
Practice Address - Street 1:1807 SMITH ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1576
Practice Address - Country:US
Practice Address - Phone:574-732-1414
Practice Address - Fax:574-732-0504
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003152A LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00109277Medicare ID - Type UnspecifiedRAILROAD MEDICARE
IN112690WMedicare ID - Type UnspecifiedMEDICARE