Healthcare Provider Details

I. General information

NPI: 1467109363
Provider Name (Legal Business Name): BRETT M WELCH MT-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E STATE BLVD
FORT WAYNE IN
46805-4728
US

IV. Provider business mailing address

2500 E STATE BLVD
FORT WAYNE IN
46805-4728
US

V. Phone/Fax

Practice location:
  • Phone: 260-426-5431
  • Fax:
Mailing address:
  • Phone: 260-426-5431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number16288
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: