Provider Demographics
NPI:1134395510
Name:INTERDISCIPLINARY DIAGNOSTIC & EVALUATION CENTER, INC.
Entity type:Organization
Organization Name:INTERDISCIPLINARY DIAGNOSTIC & EVALUATION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:PATSY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DONN
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:260-422-2838
Mailing Address - Street 1:3030 LAKE AVE STE 7
Mailing Address - Street 2:FT. WAYNE
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5428
Mailing Address - Country:US
Mailing Address - Phone:260-422-2838
Mailing Address - Fax:
Practice Address - Street 1:3030 LAKE AVE STE 7
Practice Address - Street 2:FT. WAYNE
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5428
Practice Address - Country:US
Practice Address - Phone:260-422-2838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20090014A103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100080770 AMedicaid