Basic Information
| Provider Information | |||||||||
| NPI: | 1780014696 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NERAD | ||||||||
| FirstName: | NANCY | ||||||||
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| Credential: | LCAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 645 S ROGERS ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474032353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123391691 | ||||||||
| FaxNumber: | 8123372438 | ||||||||
| Practice Location | |||||||||
| Address1: | 1175 SOUTHVIEW DR | ||||||||
| Address2: | |||||||||
| City: | MARTINSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461517062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653426616 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2013 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 87001474A | IN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 201089820A | 05 | IN | MEDICAID |