MEDICARE: POSSIBILITIES NORTHEAST, LLC.

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy
1	103TC2200X	Clinical Child & Adolescent Psychologist
2	163WP0200X	Pediatric Registered Nurse
3	225100000X	Physical Therapist
4	225X00000X	Occupational Therapist
5	373H00000X	Day Training/Habilitation Specialist
6	103K00000X	Behavior Analyst
7	235Z00000X	Speech-Language Pathologist

#	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
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1881734697
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POSSIBILITIES NORTHEAST, LLC.

Provider Business Mailing Address
First Line	:	PO BOX 80867
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46898-0867
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4935 HILLEGAS RD STE 200
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-1934
Country	:	US
Telephone Number	:	260-338-1241
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	NANCY L MOORE
Credential	:
Telephone Number	:	260-338-1241

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	02/26/2016

4935 HILLEGAS RD
FORT WAYNE, IN
46818-1934

Practice Phone: 260-338-1241
Practice Fax:

4935 HILLEGAS RD
FORT WAYNE, IN
46818-1934