Healthcare Provider Details

I. General information

NPI: 1851421929
Provider Name (Legal Business Name): INTEGRAL HEALTH PSYCHOLOGY SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 S MIRAMAR WAY
MUNCIE IN
47304-6723
US

IV. Provider business mailing address

605 S MIRAMAR WAY
MUNCIE IN
47304-6723
US

V. Phone/Fax

Practice location:
  • Phone: 765-281-1442
  • Fax:
Mailing address:
  • Phone: 765-281-1442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20041132A
License Number StateIN

VIII. Authorized Official

Name: DR. DANIEL JOHN BRODERICK
Title or Position: PRESIDENT
Credential: PHD
Phone: 765-808-1687