Healthcare Provider Details

I. General information

NPI: 1275126955
Provider Name (Legal Business Name): UJIMA THERAPEUTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2021
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 LAKE AVE STE 270
FORT WAYNE IN
46805-5352
US

IV. Provider business mailing address

2250 LAKE AVE STE 270
FORT WAYNE IN
46805-5352
US

V. Phone/Fax

Practice location:
  • Phone: 260-418-6080
  • Fax:
Mailing address:
  • Phone: 260-418-6080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. OLINKA LASHAE CLARK
Title or Position: EXECUTIVE DIRECTOR
Credential: MSW
Phone: 260-418-6080