Basic Information
| Provider Information | |||||||||
| NPI: | 1144322777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANBAALEN | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DR # 117 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451701 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5693 YMCA PARK DR W | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468353280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604256500 | ||||||||
| FaxNumber: | 2604256505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2006 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34003564A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 742863000 | 01 | IN | MAGELLAN | OTHER | 200467310A | 05 | IN | MEDICAID | 000000341875 | 01 | IN | ANTHEM BCBS | OTHER | 030305 | 01 | IN | MHN | OTHER | 7733638 | 01 | IN | AETNA | OTHER |