Healthcare Provider Details

I. General information

NPI: 1821115569
Provider Name (Legal Business Name): CHILDREN'S SANCTUARY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 RUPP DR SUITE 105
FORT WAYNE IN
46815-4523
US

IV. Provider business mailing address

3711 RUPP DR SUITE 105
FORT WAYNE IN
46815-4523
US

V. Phone/Fax

Practice location:
  • Phone: 260-485-0870
  • Fax:
Mailing address:
  • Phone: 260-485-0870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number53527
License Number StateIN

VIII. Authorized Official

Name: MS. CLAIRE K. OBERLE
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 260-485-0870