Healthcare Provider Details

I. General information

NPI: 1184547259
Provider Name (Legal Business Name): FORT WAYNE MENTAL HEALTH THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6319 MUTUAL DR STE F
FORT WAYNE IN
46825-4246
US

IV. Provider business mailing address

6319 MUTUAL DR STE F
FORT WAYNE IN
46825-4246
US

V. Phone/Fax

Practice location:
  • Phone: 260-209-4388
  • Fax:
Mailing address:
  • Phone: 260-209-4388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ALYSE PIAZZA
Title or Position: CEO
Credential: LMHC.
Phone: 260-385-8744