Provider Demographics
NPI:1285723122
Name:VANDERWATER-PIERCY, JEFFREY WILLIAM (PHD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:WILLIAM
Last Name:VANDERWATER-PIERCY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8206 ROCKVILLE RD
Mailing Address - Street 2:#134
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-3113
Mailing Address - Country:US
Mailing Address - Phone:765-446-0533
Mailing Address - Fax:765-446-0534
Practice Address - Street 1:30 PROFESSIONAL CT
Practice Address - Street 2:SUITE 3
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5179
Practice Address - Country:US
Practice Address - Phone:765-446-0533
Practice Address - Fax:765-446-0534
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040366A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN815920Medicare ID - Type Unspecified