Provider Demographics
NPI:1003983115
Name:MONROE, LINDA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:
Last Name:MONROE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 GRAPE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3015
Mailing Address - Country:US
Mailing Address - Phone:574-243-9370
Mailing Address - Fax:574-243-9375
Practice Address - Street 1:2410 GRAPE RD STE 1
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3015
Practice Address - Country:US
Practice Address - Phone:574-243-9370
Practice Address - Fax:574-243-9375
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011586103TC0700X
IN20040361A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN351877953OtherTRICARE PROVIDER NUMBER
IN100091350CMedicaid
IN351877953OtherTRICARE PROVIDER NUMBER
IN351877953OtherTRICARE PROVIDER NUMBER
IN024505000OtherMAGELLAN