Basic Information
| Provider Information | |||||||||
| NPI: | 1780638619 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACKHAUS | ||||||||
| FirstName: | SOUGANDHI | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6804 WOOD HAVEN PL | ||||||||
| Address2: | |||||||||
| City: | ZIONSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460778560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178798940 | ||||||||
| FaxNumber: | 3178720914 | ||||||||
| Practice Location | |||||||||
| Address1: | 4141 SHORE DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462542607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173292219 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 07/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 20041993 | IN | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | 20041993 | IN | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 200285860 | 05 | IN | MEDICAID |