Provider Demographics
NPI:1750521837
Name:SUBECK, PHILLIP I (LCSW)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:I
Last Name:SUBECK
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 1:115 FARABEE DR N
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-5913
Mailing Address - Country:US
Mailing Address - Phone:765-404-9023
Mailing Address - Fax:765-423-5600
Practice Address - Street 1:115 FARABEE DR N
Practice Address - Street 2:SUITE B-2
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5913
Practice Address - Country:US
Practice Address - Phone:765-404-9023
Practice Address - Fax:765-423-5600
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-02
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9923281041C0700X
IN34005906A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical