Provider Demographics
NPI:1700871977
Name:KADLEC, MARY M (PSYD HSPP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:KADLEC
Suffix:
Gender:F
Credentials:PSYD HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4214 HOBSON CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-8648
Mailing Address - Country:US
Mailing Address - Phone:260-486-5251
Mailing Address - Fax:260-486-5058
Practice Address - Street 1:4214 HOBSON CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-8648
Practice Address - Country:US
Practice Address - Phone:260-486-5251
Practice Address - Fax:260-486-5058
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040944A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0007607161OtherAETNA US HEALTHCARE
256981OtherVALUE OPTIONS
000000296403OtherANTHEM
IN20027420AMedicaid
36768OtherCIGNA
000000296403OtherANTHEM
0007607161OtherAETNA US HEALTHCARE