| Interdisciplinary Diagnostic & Evaluation Center, Inc. | |
|
3030 Lake Ave Ste 7 Ft. Wayne Fort Wayne IN 46805-5428 | |
| (260) 422-2838 | |
| Not Available |
| Full Name | Interdisciplinary Diagnostic & Evaluation Center, Inc. |
|---|---|
| Speciality | Psychologist - Intellectual & Developmental Disabilities |
| Location | 3030 Lake Ave Ste 7, Fort Wayne, Indiana |
| Authorized Official Name and Position | Patsy A. Donn (PRESIDENT AND CFO) |
| Authorized Official Contact | 2604222838 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Interdisciplinary Diagnostic & Evaluation Center, Inc. 3030 Lake Ave Ste 7 Ft. Wayne Fort Wayne IN 46805-5428 Ph: (260) 422-2838 | Interdisciplinary Diagnostic & Evaluation Center, Inc. 3030 Lake Ave Ste 7 Ft. Wayne Fort Wayne IN 46805-5428 Ph: (260) 422-2838 |
| NPI Number | 1134395510 |
|---|---|
| Provider Enumeration Date | 05/05/2008 |
| Last Update Date | 05/05/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1134395510 | NPI | - | NPPES |
| 100080770 A | Medicaid | IN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TM1800X | Psychologist - Intellectual & Developmental Disabilities | 20090014A (Indiana) | Primary |
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