MEDICARE: CENTER FOR BRIEF THERAPY PC

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	103TH0100X	Health Service Psychologist	20042050A	IN
2	106H00000X	Marriage & Family Therapist	35001565A	IN
3	103TP0016X	Prescribing (Medical) Psychologist	70000153A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7585825	OTHER	IN	AETNA
2	376137	OTHER	IN	ANTHEM
3	386107	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1285839480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTER FOR BRIEF THERAPY PC

Provider Business Mailing Address
First Line	:	423 AIRPORT N. OFFICE PARK
Second Line	:
City	:	FORT. WAYNE
State	:	IN
Zip	:	46825-6704
Country	:	US
Telephone Number	:	260-969-5583
Fax Number	:	260-969-5584

Provider Business Practice Location Address
First Line	:	423 AIRPORT N. OFFICE PARK
Second Line	:
City	:	FT. WAYNE
State	:	IN
Zip	:	46825-6704
Country	:	US
Telephone Number	:	260-969-5583
Fax Number	:	260-969-5584

Authorized Official
Title or Position	:	OWNER
Name	:	SHARON E FREEMAN CLEVENGER
Credential	:	PMHCNS-BC
Telephone Number	:	260-969-5583

Provider Enumeration Date	:	06/18/2007
Last Update Date	:	04/23/2019

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Directions to “CENTER FOR BRIEF THERAPY PC ” Practice Location

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