Provider Demographics
NPI:1437459583
Name:WALETICH, REBECCA JEAN (LCSW)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:JEAN
Last Name:WALETICH
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:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49204-0047
Mailing Address - Country:US
Mailing Address - Phone:317-210-1131
Mailing Address - Fax:317-215-5766
Practice Address - Street 1:2437 SHELBY ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-4252
Practice Address - Country:US
Practice Address - Phone:317-557-5091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004596A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical