Provider Demographics
NPI:1538210166
Name:ULLRICH, DEAN (MSW)
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:
Last Name:ULLRICH
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3174 MALLARD COVE LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2882
Mailing Address - Country:US
Mailing Address - Phone:260-432-7510
Mailing Address - Fax:260-432-8512
Practice Address - Street 1:3174 MALLARD COVE LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2882
Practice Address - Country:US
Practice Address - Phone:260-432-7510
Practice Address - Fax:260-432-8512
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000828A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN039365OtherVALUEOPTIONS
IN0007668135OtherAETNA PIN
IN000000176433OtherBLUE CROSS BLUE SHIELD
IN185020Medicare ID - Type Unspecified