Healthcare Provider Details

I. General information

NPI: 1891631073
Provider Name (Legal Business Name): IVY BRIDGE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 WEST JEFFERSON BLVD SUITE 230
FORT WAYNE IN
46804
US

IV. Provider business mailing address

5534 SAINT JOE RD
FORT WAYNE IN
46835-3328
US

V. Phone/Fax

Practice location:
  • Phone: 260-267-5491
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: HANNAH LOGA
Title or Position: FOUNDER
Credential: LMHC
Phone: 812-630-8892