Healthcare Provider Details

I. General information

NPI: 1285839480
Provider Name (Legal Business Name): CENTER FOR BRIEF THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 AIRPORT N. OFFICE PARK
FT. WAYNE IN
46825-6704
US

IV. Provider business mailing address

423 AIRPORT N. OFFICE PARK
FORT. WAYNE IN
46825-6704
US

V. Phone/Fax

Practice location:
  • Phone: 260-969-5583
  • Fax: 260-969-5584
Mailing address:
  • Phone: 260-969-5583
  • Fax: 260-969-5584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number20042050A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001565A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number70000153A
License Number StateIN

VIII. Authorized Official

Name: SHARON E FREEMAN CLEVENGER
Title or Position: OWNER
Credential: PMHCNS-BC
Phone: 260-969-5583