MEDICARE: MARY LISA BARTA 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	106H00000X	Marriage & Family Therapist	35001710A	IN

General Provider Information

NPI Number	:	1922497775
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY LISA BARTA LLC

Provider Business Mailing Address
First Line	:	5630 THE PROPHETS PASS
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9473
Country	:	US
Telephone Number	:	260-471-1662
Fax Number	:

Provider Business Practice Location Address
First Line	:	5630 THE PROPHETS PASS
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9473
Country	:	US
Telephone Number	:	260-471-1662
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	MARY LISA BARTA
Credential	:
Telephone Number	:	260-471-1662

Provider Enumeration Date	:	01/16/2015
Last Update Date	:	01/16/2015

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Directions to “MARY LISA BARTA LLC ” Practice Location

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