Healthcare Provider Details

I. General information

NPI: 1942972047
Provider Name (Legal Business Name): INDIANA PSYCHIATRIC ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4656 W JEFFERSON BLVD STE 201
FORT WAYNE IN
46804-6857
US

IV. Provider business mailing address

4656 W JEFFERSON BLVD STE 201
FORT WAYNE IN
46804-6857
US

V. Phone/Fax

Practice location:
  • Phone: 978-000-0001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. SATYA KISHORE GUTTA
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 260-208-9676