Provider Demographics
NPI:1679741235
Name:MICHAEL L RUPLEY PHD PC
Entity type:Organization
Organization Name:MICHAEL L RUPLEY PHD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD HSPP PC
Authorized Official - Phone:574-256-2258
Mailing Address - Street 1:323 WEST 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-1913
Mailing Address - Country:US
Mailing Address - Phone:574-256-2258
Mailing Address - Fax:574-256-2266
Practice Address - Street 1:323 WEST 4TH STREET
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1913
Practice Address - Country:US
Practice Address - Phone:574-256-2258
Practice Address - Fax:574-256-2266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-18
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010350103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000214616OtherANTHEM BLUE CROSS
IN100089740Medicaid
IN100089740AMedicaid
IN737799Medicare UPIN
IN100089740Medicaid
IN100089740AMedicaid