Provider Demographics
NPI:1821249079
Name:GARY M. DURAK, PH.D., P.C.
Entity Type:Organization
Organization Name:GARY M. DURAK, PH.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGSIT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DURAK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:219-464-7678
Mailing Address - Street 1:307 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-4823
Mailing Address - Country:US
Mailing Address - Phone:219-464-7678
Mailing Address - Fax:219-462-8351
Practice Address - Street 1:307 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-4823
Practice Address - Country:US
Practice Address - Phone:219-464-7678
Practice Address - Fax:219-462-8351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20090233A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100298960AMedicaid
IN656530Medicare PIN