Provider Demographics
NPI:1083431860
Name:BACEWIC, DARIANE JO (MED EDS NCSP IPE)
Entity type:Individual
Prefix:
First Name:DARIANE
Middle Name:JO
Last Name:BACEWIC
Suffix:
Gender:F
Credentials:MED EDS NCSP IPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2249 S 250 W
Mailing Address - Street 2:
Mailing Address - City:NORTH JUDSON
Mailing Address - State:IN
Mailing Address - Zip Code:46366-8673
Mailing Address - Country:US
Mailing Address - Phone:219-510-7020
Mailing Address - Fax:
Practice Address - Street 1:801 CAMPBELL DR
Practice Address - Street 2:
Practice Address - City:NORTH JUDSON
Practice Address - State:IN
Practice Address - Zip Code:46366-1359
Practice Address - Country:US
Practice Address - Phone:574-896-2128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10268930103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool