Basic Information
Provider Information | |||||||||
NPI: | 1518244151 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GERDES | ||||||||
FirstName: | DEBORAH | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSY.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SERBER | ||||||||
OtherFirstName: | DEBORAH | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PSY.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3700 W KILGORE AVE | ||||||||
Address2: |   | ||||||||
City: | MUNCIE | ||||||||
State: | IN | ||||||||
PostalCode: | 473044810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7652895437 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 13819 HANSON BLVD NW | ||||||||
Address2: |   | ||||||||
City: | ANDOVER | ||||||||
State: | MN | ||||||||
PostalCode: | 55304 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6126726999 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2011 | ||||||||
LastUpdateDate: | 07/06/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CC01422 | MN | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor |   |
No ID Information.