Provider Demographics
NPI:1639360886
Name:DENNIS, MICHAEL ADAM (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ADAM
Last Name:DENNIS
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 1:9531 VALPARAISO CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-1130
Mailing Address - Country:US
Mailing Address - Phone:317-329-2000
Mailing Address - Fax:
Practice Address - Street 1:3010 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4700
Practice Address - Country:US
Practice Address - Phone:260-471-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INNA103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical