MEDICARE: KURT H. GREGORY D.B.A. FAMILY SUPPORT SERVICES OF NORTHEN INDIANA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	35001414A	IN

General Provider Information

NPI Number	:	1023098134
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KURT H. GREGORY D.B.A. FAMILY SUPPORT SERVICES OF NORTHEN INDIANA

Provider Business Mailing Address
First Line	:	7311B W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-6237
Country	:	US
Telephone Number	:	260-432-2311
Fax Number	:	260-432-2311

Provider Business Practice Location Address
First Line	:	7311B W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-6237
Country	:	US
Telephone Number	:	260-432-2311
Fax Number	:	260-432-2311

Authorized Official
Title or Position	:	OWNER
Name	:	MR. KURT H. GREGORY
Credential	:	L.M.F.T.
Telephone Number	:	260-244-0057

Provider Enumeration Date	:	01/17/2006
Last Update Date	:	06/23/2008

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