Healthcare Provider Details

I. General information

NPI: 1356779722
Provider Name (Legal Business Name): MARY E LEINS PSYD, HSPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2013
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 WASHINGTON AVE # 100
EVANSVILLE IN
47714-0550
US

IV. Provider business mailing address

3900 WASHINGTON AVE # 100
EVANSVILLE IN
47714-0550
US

V. Phone/Fax

Practice location:
  • Phone: 812-485-6694
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2013-70
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20043404A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: