Healthcare Provider Details

I. General information

NPI: 1285928176
Provider Name (Legal Business Name): HEATH H FERVIDA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 06/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 W LINCOLN AVE
GOSHEN IN
46526-5907
US

IV. Provider business mailing address

1930 W LINCOLN AVE
GOSHEN IN
46526-5907
US

V. Phone/Fax

Practice location:
  • Phone: 574-534-2161
  • Fax: 574-534-3887
Mailing address:
  • Phone: 574-534-2161
  • Fax: 574-534-3887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042483A
License Number StateIN

VIII. Authorized Official

Name: HEATH HERBERT FERVIDA
Title or Position: OWNER
Credential: PSYD, HSPP
Phone: 574-534-2161