Provider Demographics
NPI:1992234280
Name:VERSAW, RACHAEL L (MSW, LSW)
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:L
Last Name:VERSAW
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:RACHAEL
Other - Middle Name:L
Other - Last Name:KNOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LSW
Mailing Address - Street 1:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-764-5380
Practice Address - Street 1:714 LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3353
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:219-728-1639
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33008745A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)