Healthcare Provider Details

I. General information

NPI: 1023221207
Provider Name (Legal Business Name): COMPREHENSIVE BEHAVIORAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2809 E DUPONT RD
FORT WAYNE IN
46825-1668
US

IV. Provider business mailing address

2809 E DUPONT RD
FORT WAYNE IN
46825-1668
US

V. Phone/Fax

Practice location:
  • Phone: 260-492-5500
  • Fax: 260-492-5530
Mailing address:
  • Phone: 260-492-5500
  • Fax: 260-492-5530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39001423A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2004070712A
License Number StateIN

VIII. Authorized Official

Name: MRS. GAYLE BEVILL-DADA
Title or Position: PRESIDENT/COO
Credential: MS, LMHC
Phone: 260-492-5500