Provider Demographics
NPI:1770769259
Name:BACH, CONSTANCE (MS, MT-BC)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:BACH
Suffix:
Gender:F
Credentials:MS, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 E BRONSON ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-1141
Mailing Address - Country:US
Mailing Address - Phone:574-287-8342
Mailing Address - Fax:
Practice Address - Street 1:1213 E BRONSON ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-1141
Practice Address - Country:US
Practice Address - Phone:574-287-8342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08208225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200939840 AMedicaid