Basic Information
| Provider Information | |||||||||
| NPI: | 1295819571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WARD | ||||||||
| FirstName: | WESLEY | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | PH.D., HSPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3124 DOVER LN | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479096752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657421816 | ||||||||
| FaxNumber: | 7657422557 | ||||||||
| Practice Location | |||||||||
| Address1: | 3660 ROME DR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479054488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654469394 | ||||||||
| FaxNumber: | 7654478875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 07/26/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 20040478A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 100117360A | 05 | IN | MEDICAID |