Healthcare Provider Details

I. General information

NPI: 1649260977
Provider Name (Legal Business Name): MARILYN ANN ROYSDON CADAC II
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 N HARRISON ST
WARSAW IN
46580-3163
US

IV. Provider business mailing address

990 ILLINOIS ST
PLYMOUTH IN
46563-3622
US

V. Phone/Fax

Practice location:
  • Phone: 574-267-7169
  • Fax: 574-269-3995
Mailing address:
  • Phone: 574-936-9646
  • Fax: 574-936-4773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC1052
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: