Healthcare Provider Details

I. General information

NPI: 1336224781
Provider Name (Legal Business Name): DOMINIC VACHON PHD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

837 CEDAR ST STE 100
SOUTH BEND IN
46617-2069
US

IV. Provider business mailing address

837 CEDAR ST STE 100
SOUTH BEND IN
46617-2069
US

V. Phone/Fax

Practice location:
  • Phone: 574-237-7338
  • Fax: 574-237-7881
Mailing address:
  • Phone: 574-237-7338
  • Fax: 574-237-7881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20040854
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: