Provider Demographics
NPI:1003946708
Name:SELF, RITA KAY (MS)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:KAY
Last Name:SELF
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3742
Mailing Address - Country:US
Mailing Address - Phone:260-482-7871
Mailing Address - Fax:260-745-0405
Practice Address - Street 1:3010 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4700
Practice Address - Country:US
Practice Address - Phone:260-471-2300
Practice Address - Fax:260-471-2778
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
INNOT YET LICENSED101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health