Healthcare Provider Details

I. General information

NPI: 1871032862
Provider Name (Legal Business Name): FORT WAYNE NEUROPSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2017
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4306 E STATE BLVD
FORT WAYNE IN
46815-6915
US

IV. Provider business mailing address

4306 E STATE BLVD
FORT WAYNE IN
46815-6915
US

V. Phone/Fax

Practice location:
  • Phone: 260-460-3100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: TASHA H. WILLIAMS
Title or Position: VICE PRESIDENT
Credential: PH.D.
Phone: 260-414-8629