=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992974620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIANA PROFESSIONAL PSYCHOLOGICAL SERVICES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2008
-----------------------------------------------------
Last Update Date | 11/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6408 CONSTITUTION DR
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46804-1558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-469-0090
-----------------------------------------------------
Fax | 260-469-0091
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6408 CONSTITUTION DR
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46804-1558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-469-0090
-----------------------------------------------------
Fax | 260-469-0091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST, PRESIDENT IPPS
-----------------------------------------------------
Name | DR. DANIEL LEE BANEY
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 260-469-0090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 20040759A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------