Healthcare Provider Details

I. General information

NPI: 1063525616
Provider Name (Legal Business Name): RALPH MERRILL WETZEL M.DIV, S.T.M, D.MIN.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 LAKE AVE 125-F
FORT WAYNE IN
46805-5100
US

IV. Provider business mailing address

4310 ARA DR P.O. BOX 286
WOODBURN IN
46797-9588
US

V. Phone/Fax

Practice location:
  • Phone: 260-426-5431
  • Fax: 260-460-1402
Mailing address:
  • Phone: 260-493-3695
  • Fax: 260-493-3322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: