Provider Demographics
NPI:1215083431
Name:AMIDON, DEBRA JEAN (LCSW)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:JEAN
Last Name:AMIDON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-0817
Mailing Address - Country:US
Mailing Address - Phone:260-347-2453
Mailing Address - Fax:260-347-2456
Practice Address - Street 1:1930 DOWLING ST
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-9436
Practice Address - Country:US
Practice Address - Phone:260-347-4400
Practice Address - Fax:260-347-3122
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004904A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN34004904AOtherLICENSE
IN581480TMedicare PIN