Provider Demographics
NPI:1366899130
Name:VITELA, JUAN-ESTEFAN (LCSW)
Entity type:Individual
Prefix:
First Name:JUAN-ESTEFAN
Middle Name:
Last Name:VITELA
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 1:706 RIDGE RD STE B
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1612
Mailing Address - Country:US
Mailing Address - Phone:219-356-2240
Mailing Address - Fax:
Practice Address - Street 1:706 RIDGE RD STE B
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1612
Practice Address - Country:US
Practice Address - Phone:219-356-2240
Practice Address - Fax:219-356-2241
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-20
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness