Healthcare Provider Details

I. General information

NPI: 1639285232
Provider Name (Legal Business Name): PSYCHOLOGY ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 W CATALPA DR SUITE E
MISHAWAKA IN
46545-3194
US

IV. Provider business mailing address

314 W CATALPA DR SUITE E
MISHAWAKA IN
46545-3194
US

V. Phone/Fax

Practice location:
  • Phone: 574-254-1700
  • Fax: 574-254-2930
Mailing address:
  • Phone: 574-254-1700
  • Fax: 574-254-2930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number57000021A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number57000021A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number57000021A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number57000021A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number57000021A
License Number StateIN

VIII. Authorized Official

Name: DR. GARY W. ELLIOTT
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 574-254-1700