Provider Demographics
NPI:1023221207
Name:COMPREHENSIVE BEHAVIORAL SERVICES, LLC
Entity Type:Organization
Organization Name:COMPREHENSIVE BEHAVIORAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEVILL-DADA
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LMHC
Authorized Official - Phone:260-492-5500
Mailing Address - Street 1:2809 E DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1668
Mailing Address - Country:US
Mailing Address - Phone:260-492-5500
Mailing Address - Fax:260-492-5530
Practice Address - Street 1:2809 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1668
Practice Address - Country:US
Practice Address - Phone:260-492-5500
Practice Address - Fax:260-492-5530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001423A101YM0800X
IN2004070712A103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100332280Medicaid
IN1023221207Medicaid
IN1053488197Medicaid
IN1053488197Medicaid