Provider Demographics
NPI:1912983412
Name:HOUSTON, CYNTHIA ALLISON (MED CAGS LCSW LMFT)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ALLISON
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:MED CAGS LCSW LMFT
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:ALLISON
Other - Last Name:AUDETTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:812-339-8109
Practice Address - Street 1:645 S ROGERS ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2353
Practice Address - Country:US
Practice Address - Phone:812-339-1691
Practice Address - Fax:812-339-8109
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002414A1041C0700X
IN35000944A106H00000X
IN39000925A101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000074890OtherANTHEM
IN562970OMedicare ID - Type Unspecified
000000074890OtherANTHEM