Provider Demographics
NPI:1750862959
Name:MICHIANA NEUROSCIENCE, LLC
Entity Type:Organization
Organization Name:MICHIANA NEUROSCIENCE, LLC
Other - Org Name:MICHIANA NEUROSCIENCE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PSYCHOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:MITCHEFF
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:574-229-9695
Mailing Address - Street 1:210 S RACE ST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2032
Mailing Address - Country:US
Mailing Address - Phone:574-229-9695
Mailing Address - Fax:
Practice Address - Street 1:210 S RACE ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2032
Practice Address - Country:US
Practice Address - Phone:574-229-9695
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:-
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042941A103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty