MEDICARE: COMPREHENSIVE BEHAVIORAL SERVICES, LLC

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	103TC1900X	Counseling Psychologist	2004070712A	IN
2	101YM0800X	Mental Health Counselor	39001423A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023221207
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMPREHENSIVE BEHAVIORAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	2809 E DUPONT RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1668
Country	:	US
Telephone Number	:	260-492-5500
Fax Number	:	260-492-5530

Provider Business Practice Location Address
First Line	:	2809 E DUPONT RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1668
Country	:	US
Telephone Number	:	260-492-5500
Fax Number	:	260-492-5530

Authorized Official
Title or Position	:	PRESIDENT/COO
Name	:	MRS. GAYLE BEVILL-DADA
Credential	:	MS, LMHC
Telephone Number	:	260-492-5500

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	06/26/2012

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