Provider Demographics
NPI:1295819571
Name:WARD, WESLEY H (PHD, HSPP)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:H
Last Name:WARD
Suffix:
Gender:M
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3124 DOVER LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-6752
Mailing Address - Country:US
Mailing Address - Phone:765-742-1816
Mailing Address - Fax:765-742-2557
Practice Address - Street 1:3660 ROME DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4488
Practice Address - Country:US
Practice Address - Phone:765-446-9394
Practice Address - Fax:765-447-8875
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040478A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100117360AMedicaid
IN070930LMedicare ID - Type Unspecified