Provider Demographics
NPI:1609868504
Name:MIHLBAUER, THERESE C (PHD)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:C
Last Name:MIHLBAUER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 S. CALHOUN STREET
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-1402
Mailing Address - Country:US
Mailing Address - Phone:260-744-4326
Mailing Address - Fax:260-744-0188
Practice Address - Street 1:2712 S CALHOUN ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-1402
Practice Address - Country:US
Practice Address - Phone:260-744-4326
Practice Address - Fax:260-744-0188
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010502A103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200730270Medicaid
IN100081280Medicaid
IN100081280Medicaid
INR33263Medicare UPIN
IN208360Medicare PIN