MEDICARE: MARY M KADLEC PSYD HSPP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	20040944A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	0007607161	OTHER	AETNA US HEALTHCARE
2	256981	OTHER	VALUE OPTIONS
3	000000296403	OTHER	ANTHEM
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	36768	OTHER	CIGNA

General Provider Information

NPI Number	:	1700871977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY M KADLEC PSYD HSPP

Provider Business Mailing Address
First Line	:	4214 HOBSON CT
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-8648
Country	:	US
Telephone Number	:	260-486-5251
Fax Number	:	260-486-5058

Provider Business Practice Location Address
First Line	:	4214 HOBSON CT
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-8648
Country	:	US
Telephone Number	:	260-486-5251
Fax Number	:	260-486-5058

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	07/08/2007

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