Provider Demographics
NPI:1386622751
Name:RAELSON, ROBERTA ANN (LCSW)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:ANN
Last Name:RAELSON
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 1:825 JUNKINS LOOP
Mailing Address - Street 2:
Mailing Address - City:WESTCLIFFE
Mailing Address - State:CO
Mailing Address - Zip Code:81252-9006
Mailing Address - Country:US
Mailing Address - Phone:219-928-6422
Mailing Address - Fax:
Practice Address - Street 1:601 WALL ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2512
Practice Address - Country:US
Practice Address - Phone:219-531-3500
Practice Address - Fax:219-462-3975
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003544A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000325401OtherANTHEM
IN34003544AOtherLCSW
6595900Medicare ID - Type Unspecified
IN000000325401OtherANTHEM
P00228935Medicare ID - Type UnspecifiedRR