Provider Demographics
NPI:1144322777
Name:VANBAALEN, TAMARA L (LCSW)
Entity type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:L
Last Name:VANBAALEN
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5693 YMCA PARK DR W
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-3280
Practice Address - Country:US
Practice Address - Phone:260-425-6500
Practice Address - Fax:260-425-6505
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003564A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN742863000OtherMAGELLAN
IN200467310AMedicaid
IN000000341875OtherANTHEM BCBS
IN030305OtherMHN
IN7733638OtherAETNA