Healthcare Provider Details

I. General information

NPI: 1780638619
Provider Name (Legal Business Name): SOUGANDHI BACKHAUS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 07/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 SHORE DR
INDIANAPOLIS IN
46254-2607
US

IV. Provider business mailing address

6804 WOOD HAVEN PL
ZIONSVILLE IN
46077-8560
US

V. Phone/Fax

Practice location:
  • Phone: 317-329-2219
  • Fax:
Mailing address:
  • Phone: 317-879-8940
  • Fax: 317-872-0914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number20041993
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20041993
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: