Provider Demographics
NPI:1083184196
Name:FAMILY PSYCHOLOGY OF SOUTH BEND LLC
Entity Type:Organization
Organization Name:FAMILY PSYCHOLOGY OF SOUTH BEND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:574-280-8199
Mailing Address - Street 1:922 E WAYNE ST STE 205
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-3024
Mailing Address - Country:US
Mailing Address - Phone:574-280-8199
Mailing Address - Fax:
Practice Address - Street 1:922 E WAYNE ST STE 205
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3024
Practice Address - Country:US
Practice Address - Phone:574-280-8199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-01
Last Update Date:2018-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty