Facts
- Status
- A
- Credential
- PsyD, HSPP
- Type
- Individual
- Enumeration date
- 2019-03-11
- Last updated
- 2019-03-11
Licenses
- License IL
- 071009344
- License IN
- 20042935A
Location
- Practice location
- 4490 REFORMATORY RD
- City
- PENDLETON IN
- Postal code
- 460649001
- Phone
- 765-778-2107
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.