MEDICARE: KELLY L HOOVER PH.D., HSPP

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	20043293B	IN

General Provider Information

NPI Number	:	1447891312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY L HOOVER PH.D., HSPP

Provider Business Mailing Address
First Line	:	4306 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6915
Country	:	US
Telephone Number	:	260-460-3203
Fax Number	:	260-460-3271

Provider Business Practice Location Address
First Line	:	4306 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6915
Country	:	US
Telephone Number	:	260-460-3203
Fax Number	:	260-460-3271

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

Provider Enumeration Date	:	10/02/2019
Last Update Date	:	10/02/2019

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