MEDICARE: CATHERINE SALLAZ MHC

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	101YM0800X	Mental Health Counselor	39002872A	IN

General Provider Information

NPI Number	:	1134630387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CATHERINE SALLAZ MHC

Provider Business Mailing Address
First Line	:	3120 MALLARD COVE LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2882
Country	:	US
Telephone Number	:	260-459-6095
Fax Number	:

Provider Business Practice Location Address
First Line	:	3120 MALLARD COVE LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2882
Country	:	US
Telephone Number	:	260-459-6095
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2017
Last Update Date	:	12/30/2020

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