Provider Demographics
NPI:1932148095
Name:YODER, PAUL J (HSPP)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:YODER
Suffix:
Gender:M
Credentials:HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-9365
Mailing Address - Country:US
Mailing Address - Phone:574-533-1234
Mailing Address - Fax:
Practice Address - Street 1:330 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-9365
Practice Address - Country:US
Practice Address - Phone:574-533-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040072A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000202228OtherANTHEM PIN
IN200014860Medicaid
IN200014860Medicaid