Provider Demographics
NPI:1912922550
Name:GLOBE STAR, LLC
Entity Type:Organization
Organization Name:GLOBE STAR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MCCROVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-921-5492
Mailing Address - Street 1:621 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-2259
Mailing Address - Country:US
Mailing Address - Phone:219-921-5492
Mailing Address - Fax:219-921-0143
Practice Address - Street 1:621 BROADWAY
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2259
Practice Address - Country:US
Practice Address - Phone:219-921-5492
Practice Address - Fax:219-921-0143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X
IN100110700103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100110700Medicaid