Basic Information
Provider Information | |||||||||
NPI: | 1396141032 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COMER | ||||||||
FirstName: | KRYSTIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW, LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GERIG | ||||||||
OtherFirstName: | KRYSTIE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 809 | ||||||||
Address2: |   | ||||||||
City: | GOSHEN | ||||||||
State: | IN | ||||||||
PostalCode: | 465270809 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5745331234 | ||||||||
FaxNumber: | 5745372652 | ||||||||
Practice Location | |||||||||
Address1: | 415 E MADISON ST | ||||||||
Address2: |   | ||||||||
City: | SOUTH BEND | ||||||||
State: | IN | ||||||||
PostalCode: | 466172322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5745331234 | ||||||||
FaxNumber: | 5745372652 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2014 | ||||||||
LastUpdateDate: | 02/26/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor |   | 1041C0700X | 34007810A | IN | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.