Healthcare Provider Details

I. General information

NPI: 1609812767
Provider Name (Legal Business Name): GARY M DURAK PH D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 06/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 NAPOLEON ST
VALPARAISO IN
46383-4725
US

IV. Provider business mailing address

7 NAPOLEON ST
VALPARAISO IN
46383-4725
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-7678
  • Fax: 219-464-0941
Mailing address:
  • Phone: 219-464-7678
  • Fax: 219-464-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20090233A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: