Healthcare Provider Details

I. General information

NPI: 1336117498
Provider Name (Legal Business Name): MARY JANE MULVEY GANDOUR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 UNION ST SUITE 101
LAFAYETTE IN
47904-2694
US

IV. Provider business mailing address

PO BOX 4699
LAFAYETTE IN
47903-4699
US

V. Phone/Fax

Practice location:
  • Phone: 765-449-8286
  • Fax: 765-449-0445
Mailing address:
  • Phone: 765-449-8286
  • Fax: 765-449-0445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20040331A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: