Basic Information
| Provider Information | |||||||||
| NPI: | 1619569225 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHADWELL | ||||||||
| FirstName: | ALLEY | ||||||||
| MiddleName: | FANESI | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LISW, LICDC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | ALLEY | ||||||||
| OtherMiddleName: | FANESI | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 223 | ||||||||
| Address2: | |||||||||
| City: | BATESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 470060223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129335441 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11137 US HIGHWAY 52 | ||||||||
| Address2: | |||||||||
| City: | BROOKVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 470127901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656475126 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2021 | ||||||||
| LastUpdateDate: | 05/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 34009220A | IN | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 34009220A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.