Provider Demographics
NPI:1780888727
Name:MID-AMERICA PSYCHOLOGICAL & COUNSELING SERVICE P.C.
Entity type:Organization
Organization Name:MID-AMERICA PSYCHOLOGICAL & COUNSELING SERVICE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KALYANI
Authorized Official - Middle Name:
Authorized Official - Last Name:GOPAL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:219-736-1000
Mailing Address - Street 1:7725 BROADWAY
Mailing Address - Street 2:STE A
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-4728
Mailing Address - Country:US
Mailing Address - Phone:219-736-1000
Mailing Address - Fax:219-736-9699
Practice Address - Street 1:7725 BROADWAY
Practice Address - Street 2:STE A
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-4728
Practice Address - Country:US
Practice Address - Phone:219-736-1000
Practice Address - Fax:219-736-9699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041200A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN=========OtherTAX ID