Healthcare Provider Details

I. General information

NPI: 1467406538
Provider Name (Legal Business Name): REVATHI B BINGI ED.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 SAINT JOE CENTER RD SUITE 44
FORT WAYNE IN
46825-5000
US

IV. Provider business mailing address

1910 SAINT JOE CENTER RD SUITE 44
FORT WAYNE IN
46825-5000
US

V. Phone/Fax

Practice location:
  • Phone: 260-471-8033
  • Fax: 260-471-8107
Mailing address:
  • Phone: 260-471-8033
  • Fax: 260-471-8107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39000013A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number00248
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20041075A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number20041075A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: