Provider Demographics
NPI:1104923234
Name:WILLAGE, DEBORA ELAINE (PHD)
Entity type:Individual
Prefix:
First Name:DEBORA
Middle Name:ELAINE
Last Name:WILLAGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:DEBORA
Other - Middle Name:ELAINE
Other - Last Name:TEPPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:606 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-4708
Mailing Address - Country:US
Mailing Address - Phone:812-265-4151
Mailing Address - Fax:812-265-5028
Practice Address - Street 1:606 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-4708
Practice Address - Country:US
Practice Address - Phone:812-265-4151
Practice Address - Fax:812-265-5028
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040505A103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200041700AMedicaid
IN200041700AMedicaid