Provider Demographics
NPI:1639237902
Name:LOTAK, WILLIAM JEFFREY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JEFFREY
Last Name:LOTAK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10105 WELLINGTON TER
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-4373
Mailing Address - Country:US
Mailing Address - Phone:219-922-9299
Mailing Address - Fax:219-922-1945
Practice Address - Street 1:32 RIDGE RD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1518
Practice Address - Country:US
Practice Address - Phone:219-836-8806
Practice Address - Fax:219-922-9299
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041350A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INR25520Medicare UPIN
IN234050Medicare ID - Type Unspecified