Healthcare Provider Details

I. General information

NPI: 1982537080
Provider Name (Legal Business Name): PROFESSIONAL COUNSELING ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3154 MALLARD COVE LN
FORT WAYNE IN
46804-2882
US

IV. Provider business mailing address

3154 MALLARD COVE LN
FORT WAYNE IN
46804-2882
US

V. Phone/Fax

Practice location:
  • Phone: 260-205-8141
  • Fax: --
Mailing address:
  • Phone: 260-205-8141
  • 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: MARNI F. MASTBAUM
Title or Position: MENTAL HEALTH COUNSELOR
Credential: MS, LMHC
Phone: 260-433-5007