Provider Demographics
NPI:1851421929
Name:INTEGRAL HEALTH PSYCHOLOGY SERVICES, PC
Entity Type:Organization
Organization Name:INTEGRAL HEALTH PSYCHOLOGY SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BRODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:765-808-1687
Mailing Address - Street 1:605 S MIRAMAR WAY
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-6723
Mailing Address - Country:US
Mailing Address - Phone:765-281-1442
Mailing Address - Fax:
Practice Address - Street 1:605 S MIRAMAR WAY
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-6723
Practice Address - Country:US
Practice Address - Phone:765-281-1442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041132A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN837986000OtherMAGELLAN HEALTH SERVICES
IN000000371406OtherANTHEM BLUE CROSS
IN200532030AMedicaid
IN000000028559OtherM-PLAN
INQ4774Medicare UPIN
IN200532030AMedicaid