Provider Demographics
NPI:1336224781
Name:VACHON, DOMINIC (PHD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:
Last Name:VACHON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 CEDAR ST
Mailing Address - Street 2:STE 100
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2069
Mailing Address - Country:US
Mailing Address - Phone:574-237-7338
Mailing Address - Fax:574-237-7881
Practice Address - Street 1:837 CEDAR ST
Practice Address - Street 2:STE 100
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2069
Practice Address - Country:US
Practice Address - Phone:574-237-7338
Practice Address - Fax:574-237-7881
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040854103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN168370CMedicare ID - Type Unspecified