Provider Demographics
NPI:1851376149
Name:UDULUTCH, MARIE K (PSYD)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:K
Last Name:UDULUTCH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 N MICHIGAN ST
Mailing Address - Street 2:STE. 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1244
Mailing Address - Country:US
Mailing Address - Phone:574-647-1845
Mailing Address - Fax:574-647-1825
Practice Address - Street 1:707 N MICHIGAN ST
Practice Address - Street 2:STE. 400
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1067
Practice Address - Country:US
Practice Address - Phone:574-647-1068
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040909A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INS18984Medicare UPIN