Provider Demographics
NPI:1417401167
Name:THUILLARD, MARY SUSAN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:THUILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUSAN
Other - Last Name:PRATER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-0817
Mailing Address - Country:US
Mailing Address - Phone:260-347-2453
Mailing Address - Fax:260-347-2456
Practice Address - Street 1:2155 N STATE ROAD 9
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-8746
Practice Address - Country:US
Practice Address - Phone:260-463-7144
Practice Address - Fax:260-463-7146
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor