Provider Demographics
NPI:1003833096
Name:HORN, RAYMOND W (PHD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:W
Last Name:HORN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10293 N MERIDIAN ST STE 210
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1079
Mailing Address - Country:US
Mailing Address - Phone:317-581-2292
Mailing Address - Fax:317-581-2285
Practice Address - Street 1:10293 N MERIDIAN ST STE 210
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46290-1079
Practice Address - Country:US
Practice Address - Phone:317-581-2292
Practice Address - Fax:317-581-2285
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010438A103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R33502Medicare UPIN
674940Medicare ID - Type Unspecified