Healthcare Provider Details

I. General information

NPI: 1538958434
Provider Name (Legal Business Name): BENJAMIN FORTE
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2025
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GROWTH PKWY
ANGOLA IN
46703-9343
US

IV. Provider business mailing address

5601 COVENTRY LN
FORT WAYNE IN
46804-7145
US

V. Phone/Fax

Practice location:
  • Phone: 260-459-6040
  • Fax:
Mailing address:
  • Phone: 260-459-6040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-82102
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-25-15858
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-240560
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: