Healthcare Provider Details

I. General information

NPI: 1497430177
Provider Name (Legal Business Name): SOUTHWEST MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4656 W JEFFERSON BLVD STE 285
FORT WAYNE IN
46804-6838
US

IV. Provider business mailing address

4656 W JEFFERSON BLVD STE 285
FORT WAYNE IN
46804-6838
US

V. Phone/Fax

Practice location:
  • Phone: 260-422-9372
  • Fax: 260-422-0843
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINE POTTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 260-422-9372