Healthcare Provider Details

I. General information

NPI: 1265351654
Provider Name (Legal Business Name): FORT WAYNE MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5933 STONEY CREEK DR
FORT WAYNE IN
46825-4401
US

IV. Provider business mailing address

11805 WESTWIND DR
FORT WAYNE IN
46845-1337
US

V. Phone/Fax

Practice location:
  • Phone: 260-222-8510
  • Fax:
Mailing address:
  • Phone: 260-222-8510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ELISE NIEBEL
Title or Position: OWNER
Credential: MA, LMHC
Phone: 260-348-2486