Healthcare Provider Details

I. General information

NPI: 1558441063
Provider Name (Legal Business Name): PSYCHOLOGICAL SERVICE ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3421 E STATE BLVD
FORT WAYNE IN
46805-4830
US

IV. Provider business mailing address

3421 E STATE BLVD
FORT WAYNE IN
46805-4830
US

V. Phone/Fax

Practice location:
  • Phone: 260-482-8427
  • Fax: 260-482-8429
Mailing address:
  • Phone: 260-482-8427
  • Fax: 260-482-8429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number StateIN
# 7
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number StateIN
# 8
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateIN

VIII. Authorized Official

Name: JERE W LEIB
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 260-482-8427