MEDICARE: DR. LYNDA KRISTEN VATERLAUS PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY-004161	AZ
2	103TH0100X	Health Service Psychologist	PSY-004161	AZ
3	103T00000X	Psychologist	PSY-004161	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154578938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LYNDA KRISTEN VATERLAUS PSYD

Provider Business Mailing Address
First Line	:	3500 DEPAUW BLVD STE 3070
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-6135
Country	:	US
Telephone Number	:	855-324-0885
Fax Number	:	317-520-8200

Provider Business Practice Location Address
First Line	:	3602 E GREENWAY RD STE 102
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-4648
Country	:	US
Telephone Number	:	602-560-2832
Fax Number	:	317-520-8200

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2008
Last Update Date	:	05/07/2020

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