Healthcare Provider Details

I. General information

NPI: 1710435094
Provider Name (Legal Business Name): MID-AMERICA MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 WALL ST. STE 23
VALPARAISO IN
46383-2567
US

IV. Provider business mailing address

9335 CALUMET AVE. STE D
MUNSTER IN
46321-4176
US

V. Phone/Fax

Practice location:
  • Phone: 219-615-3136
  • Fax: 219-615-3147
Mailing address:
  • Phone: 219-836-9200
  • Fax: 219-836-4200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SIDARTH SINGH
Title or Position: OWNER
Credential:
Phone: 219-836-9200