Provider Demographics
NPI:1831318203
Name:NOWACK, MARY (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NOWACK
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:P O BOX 2257
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-0357
Mailing Address - Country:US
Mailing Address - Phone:219-926-8320
Mailing Address - Fax:219-926-3524
Practice Address - Street 1:4572 S HAGADORN RD STE 2AW
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5385
Practice Address - Country:US
Practice Address - Phone:517-332-1580
Practice Address - Fax:219-926-3524
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003862103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI179889OtherSELECT CARE
MI037962OtherVALUE OPTIONS
MI100 9398OtherHEALTH ADVANTAGE
MI620C34616OtherBLUE CROSS BLUE SHIELD
MI179889OtherSELECT CARE