Provider Demographics
NPI:1487951893
Name:BEANBLOSSOM, ANGELA (LCSW)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BEANBLOSSOM
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 1:4329 W MOUNT CARMEL RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IN
Mailing Address - Zip Code:47167-8258
Mailing Address - Country:US
Mailing Address - Phone:812-472-3710
Mailing Address - Fax:
Practice Address - Street 1:289 IRELAND AVE
Practice Address - Street 2:MEDDAC BLDG 851 RM 9-40
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5111
Practice Address - Country:US
Practice Address - Phone:502-624-9006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004306A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical