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General NPI Number Information
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NPI Number | 1265162846
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Entity Type | Organization
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Legal Business Name | IMPACT BEHAVIORAL SERVICES LLC
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Dates
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Enumeration Date | 06/15/2022
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Last Update Date | 06/15/2022
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Provider Practice Location Address
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Address Line | 4606 E STATE BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46815-6993
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Country | US
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Telephone | 260-740-5139
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Fax |
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Provider Business Mailing Address
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Address Line | 2918 ELMWOOD CT
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City | FORT WAYNE
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State | IN
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Zip | 46804-6100
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Country | US
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Telephone | 260-740-5139
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHAWN A WALLACE
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Credential | MS
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Telephone | 260-740-5139
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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