Healthcare Provider Details

I. General information

NPI: 1376536052
Provider Name (Legal Business Name): MARLENE PARKER HSPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 03/25/2013
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

2860 NORTHPARK AVE
HUNTINGTON IN
46750-9700
US

V. Phone/Fax

Practice location:
  • Phone: 574-267-7169
  • Fax: 574-269-3995
Mailing address:
  • Phone: 260-356-2875
  • Fax: 260-358-0611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20041950A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: