Provider Demographics
NPI:1316161037
Name:WOHLFARTH, DEDE SUE (PSYD)
Entity type:Individual
Prefix:
First Name:DEDE
Middle Name:SUE
Last Name:WOHLFARTH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8037 UNRUH DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47122-8759
Mailing Address - Country:US
Mailing Address - Phone:812-951-1878
Mailing Address - Fax:
Practice Address - Street 1:3141 HIGHWAY 335
Practice Address - Street 2:
Practice Address - City:CRANDALL
Practice Address - State:IN
Practice Address - Zip Code:47114
Practice Address - Country:US
Practice Address - Phone:812-366-4916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041671A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200446380Medicaid