Provider Demographics
NPI:1497979793
Name:QUATTROCCHI, MICHAEL R (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:QUATTROCCHI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10765 LANTERN ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-3597
Mailing Address - Country:US
Mailing Address - Phone:317-621-4181
Mailing Address - Fax:317-621-4182
Practice Address - Street 1:10765 LANTERN ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-3597
Practice Address - Country:US
Practice Address - Phone:317-621-4181
Practice Address - Fax:317-621-4182
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041865A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1060501OtherCIGNA
IN1060501OtherCIGNA