Healthcare Provider Details

I. General information

NPI: 1821249079
Provider Name (Legal Business Name): GARY M. DURAK, PH.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 JEFFERSON ST
VALPARAISO IN
46383-4823
US

IV. Provider business mailing address

307 JEFFERSON ST
VALPARAISO IN
46383-4823
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-7678
  • Fax: 219-462-8351
Mailing address:
  • Phone: 219-464-7678
  • Fax: 219-462-8351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. GARY M. DURAK
Title or Position: CLINICAL PSYCHOLOGSIT
Credential: PH.D.
Phone: 219-464-7678