Provider Demographics
NPI:1467406538
Name:BINGI, REVATHI B (EDD)
Entity Type:Individual
Prefix:DR
First Name:REVATHI
Middle Name:B
Last Name:BINGI
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 SAINT JOE CENTER RD
Mailing Address - Street 2:SUITE 44
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5000
Mailing Address - Country:US
Mailing Address - Phone:260-471-8033
Mailing Address - Fax:260-471-8107
Practice Address - Street 1:1910 SAINT JOE CENTER RD
Practice Address - Street 2:SUITE 44
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5000
Practice Address - Country:US
Practice Address - Phone:260-471-8033
Practice Address - Fax:260-471-8107
Is Sole Proprietor?:No
Enumeration Date:2006-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000013A101YM0800X
00248103T00000X
IN20041075A103TC0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN214360Medicare ID - Type Unspecified
IN667150FMedicare ID - Type Unspecified