Healthcare Provider Details

I. General information

NPI: 1518705219
Provider Name (Legal Business Name): RONALD LEE ZUKAUSKIS PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 07/17/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 KEELEY ST
EDINBURGH IN
46124-1383
US

IV. Provider business mailing address

202 KEELEY ST
EDINBURGH IN
46124-1383
US

V. Phone/Fax

Practice location:
  • Phone: 812-526-2681
  • Fax:
Mailing address:
  • Phone: 812-526-2681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1591158
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: