Healthcare Provider Details

I. General information

NPI: 1598065690
Provider Name (Legal Business Name): BETSY L DURHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1948 W BOULEVARD
KOKOMO IN
46902-6078
US

IV. Provider business mailing address

800 FULTON ST ATTN: ANNE LAWSON - CREDENTIALING
LOGANSPORT IN
46947-1577
US

V. Phone/Fax

Practice location:
  • Phone: 765-452-5437
  • Fax: 844-684-6185
Mailing address:
  • Phone: 574-205-2600
  • Fax: 574-739-1414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number35002597A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: