MEDICARE: PSYCHOLOGICAL SERVICE ASSOCIATES, INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	103TA0700X	Adult Development & Aging Psychologist	IN
2	103TB0200X	Cognitive & Behavioral Psychologist	IN
3	103TC0700X	Clinical Psychologist	IN
4	103TC2200X	Clinical Child & Adolescent Psychologist	IN
5	103TF0000X	Family Psychologist	IN
6	103TF0200X	Forensic Psychologist	IN
7	103TH0100X	Health Service Psychologist	IN
8	103T00000X	Psychologist	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000176183	OTHER	IN	BCBS GROUP

General Provider Information

NPI Number	:	1558441063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHOLOGICAL SERVICE ASSOCIATES, INC

Provider Business Mailing Address
First Line	:	3421 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4830
Country	:	US
Telephone Number	:	260-482-8427
Fax Number	:	260-482-8429

Provider Business Practice Location Address
First Line	:	3421 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4830
Country	:	US
Telephone Number	:	260-482-8427
Fax Number	:	260-482-8429

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JERE W LEIB
Credential	:	PH.D.
Telephone Number	:	260-482-8427

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	09/11/2025

Similar Medicare Providers

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46805-4830

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1992912471 — MS. NANCY SCROGHAM GEROW M.S.
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1417297839 — SPINE CENTER OF FORT WAYNE
Practice Location Address:

3417 E STATE BLVD
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Practice Fax:

1710533633 — MATTHEW CRAWFORD
Practice Location Address:

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1710715230 — KELLY MARIE PERRY FNP
Practice Location Address:

3417 E STATE BLVD
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46805-4830

Practice Phone: 260-387-6218
Practice Fax: 260-387-6352

Directions to “PSYCHOLOGICAL SERVICE ASSOCIATES, INC ” Practice Location

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