Provider Demographics
NPI: | 1538594551 |
---|---|
Name: | YBARRA, GREGORY (LCSW) |
Entity type: | Individual |
Prefix: | |
First Name: | GREGORY |
Middle Name: | |
Last Name: | YBARRA |
Suffix: | |
Gender: | M |
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: | 9615 E 148TH ST |
Mailing Address - Street 2: | SUITE 1 |
Mailing Address - City: | NOBLESVILLE |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46060-4360 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 317-587-0500 |
Mailing Address - Fax: | 317-674-0060 |
Practice Address - Street 1: | 2506 WILLOWBROOK PKWY |
Practice Address - Street 2: | SUITE 300 |
Practice Address - City: | INDIANAPOLIS |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46205-1564 |
Practice Address - Country: | US |
Practice Address - Phone: | 317-574-1254 |
Practice Address - Fax: | 317-674-0060 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2013-09-10 |
Last Update Date: | 2015-05-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 87000391A | 101YA0400X |
IN | 34006734A | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 100073590 | Medicaid |