Healthcare Provider Details

I. General information

NPI: 1013055086
Provider Name (Legal Business Name): PSYCHOLOGICAL & FAMILY CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

926 E JACKSON BLVD
ELKHART IN
46516-4351
US

IV. Provider business mailing address

926 E JACKSON BLVD
ELKHART IN
46516-4351
US

V. Phone/Fax

Practice location:
  • Phone: 574-522-6292
  • Fax: 574-522-0481
Mailing address:
  • Phone: 574-522-6292
  • Fax: 574-522-0481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number20041649A
License Number StateIN

VIII. Authorized Official

Name: DR. ROSEANN M WOODKA
Title or Position: PSYCHOLOGIST
Credential: PH. D.
Phone: 574-522-6292