Provider Demographics
NPI:1164133070
Name:ALLEN COUNTY DRUG AND ALCOHOL CONSORTIUM, INC.
Entity Type:Organization
Organization Name:ALLEN COUNTY DRUG AND ALCOHOL CONSORTIUM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:260-424-3629
Mailing Address - Street 1:532 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-2906
Mailing Address - Country:US
Mailing Address - Phone:260-422-8412
Mailing Address - Fax:
Practice Address - Street 1:532 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-2906
Practice Address - Country:US
Practice Address - Phone:260-422-8412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty