Healthcare Provider Details

I. General information

NPI: 1336190149
Provider Name (Legal Business Name): MIDWEST ADDICTION PSYCHIATRIC & PSYCHOLOGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 03/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 E. STATE BLVD STE 100
FORT WAYNE IN
46805
US

IV. Provider business mailing address

3010 E STATE BLVD SUTIE A
FORT WAYNE IN
46805-4700
US

V. Phone/Fax

Practice location:
  • Phone: 260-471-0632
  • Fax: 260-471-3451
Mailing address:
  • Phone: 260-471-0632
  • Fax: 260-471-3451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14060ASO
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14060ASO
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number14060ASO
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number14060ASO
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number14060ASO
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number14060ASO
License Number StateIN
# 7
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number14060ASO
License Number StateIN
# 8
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14060ASO
License Number StateIN
# 9
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number14060ASO
License Number StateIN
# 10
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number14060ASO
License Number StateIN
# 11
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number14060ASO
License Number StateIN

VIII. Authorized Official

Name: DR. DON A MARSHALL JR.
Title or Position: OWNER
Credential: M.D.
Phone: 260-456-7261