Healthcare Provider Details

I. General information

NPI: 1376783555
Provider Name (Legal Business Name): MS. IDAH GUDYANGA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2009
Last Update Date: 03/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 N MAIN ST SUITE 305
SOUTH BEND IN
46601-1625
US

IV. Provider business mailing address

108 N MAIN ST SUITE 305
SOUTH BEND IN
46601-1625
US

V. Phone/Fax

Practice location:
  • Phone: 574-234-3515
  • Fax: 574-234-3565
Mailing address:
  • Phone: 574-234-3515
  • Fax: 574-234-3565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: