Provider Demographics
NPI:1346232386
Name:BABCOCK, DOUGLAS (HSPP)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:BABCOCK
Suffix:
Gender:M
Credentials:HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2608
Mailing Address - Country:US
Mailing Address - Phone:765-662-3971
Mailing Address - Fax:765-668-6718
Practice Address - Street 1:505 N WABASH AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2608
Practice Address - Country:US
Practice Address - Phone:765-662-3971
Practice Address - Fax:765-668-6718
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041618A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200317560Medicaid
IN180590BMedicare ID - Type Unspecified