Healthcare Provider Details

I. General information

NPI: 1053286690
Provider Name (Legal Business Name): VIGO COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S 1ST ST
TERRE HAUTE IN
47807-3404
US

IV. Provider business mailing address

104 S 1ST ST
TERRE HAUTE IN
47807-3404
US

V. Phone/Fax

Practice location:
  • Phone: 812-462-3381
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MACKENZIE GOODMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 812-462-3381