Provider Demographics
NPI:1063884617
Name:REBECCA WALETICH LCSW LLC
Entity type:Organization
Organization Name:REBECCA WALETICH LCSW LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALETICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-779-7574
Mailing Address - Street 1:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49204-0047
Mailing Address - Country:US
Mailing Address - Phone:317-557-5091
Mailing Address - Fax:
Practice Address - Street 1:2437 SHELBY ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-4252
Practice Address - Country:US
Practice Address - Phone:317-557-5091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004596A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty