Provider Demographics
NPI:1538227756
Name:WELLINGHOFF, SEVERIN G (PHD)
Entity type:Individual
Prefix:
First Name:SEVERIN
Middle Name:G
Last Name:WELLINGHOFF
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3868
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47737-3868
Mailing Address - Country:US
Mailing Address - Phone:812-853-7391
Mailing Address - Fax:812-858-6460
Practice Address - Street 1:4233 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8900
Practice Address - Country:US
Practice Address - Phone:812-853-7391
Practice Address - Fax:812-858-6460
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040556A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL000000247637OtherANTHEM
IN100102450Medicaid
IN100102450Medicaid
IN881830AMedicare PIN
IL000000247637OtherANTHEM