Provider Demographics
NPI:1215926142
Name:KOELNDORFER, MARCIA A (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:A
Last Name:KOELNDORFER
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 1:52305 WOOD HAVEN CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-5612
Mailing Address - Country:US
Mailing Address - Phone:574-387-5598
Mailing Address - Fax:
Practice Address - Street 1:14887 STATE ROAD 23
Practice Address - Street 2:STE 3
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-5629
Practice Address - Country:US
Practice Address - Phone:574-232-2255
Practice Address - Fax:574-232-8968
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003882A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000389244OtherANTHEM
IN000000389244OtherUNICARE
IN148470NMedicare PIN