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General NPI Number Information
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NPI Number | 1548015712
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Entity Type | Organization
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Legal Business Name | THE MENTAL HEALTH CLINIC LLC
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Dates
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Enumeration Date | 04/22/2024
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Last Update Date | 04/22/2024
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Provider Practice Location Address
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Address Line | 5673 SOUTH WAYNE AVE
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City | FORT WAYNE
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State | IN
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Zip | 46807
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Country | US
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Telephone | 844-322-2114
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Fax |
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Provider Business Mailing Address
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Address Line | 5673 SOUTH WAYNE AVE
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City | FORT WAYNE
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State | IN
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Zip | 46807
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Country | US
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Telephone | 844-322-2114
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SAMANTHA RICHARD
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Credential |
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Telephone | 260-444-9128
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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