Provider Demographics
NPI:1124108733
Name:NUSOURCE EDUCATIONAL SERVICE
Entity type:Organization
Organization Name:NUSOURCE EDUCATIONAL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF OPERATIONS
Authorized Official - Prefix:MISS
Authorized Official - First Name:KATHERLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:THEDFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-980-6217
Mailing Address - Street 1:4270 OHIO ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46409-2006
Mailing Address - Country:US
Mailing Address - Phone:219-980-6217
Mailing Address - Fax:219-985-8772
Practice Address - Street 1:4270 OHIO ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-2006
Practice Address - Country:US
Practice Address - Phone:219-980-6217
Practice Address - Fax:219-985-8772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)