Provider Demographics
NPI:1285839480
Name:CENTER FOR BRIEF THERAPY PC
Entity Type:Organization
Organization Name:CENTER FOR BRIEF THERAPY PC
Other - Org Name:INDIANA CENTER FOR COGNITIVE BEHAVIOR THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:E
Authorized Official - Last Name:FREEMAN CLEVENGER
Authorized Official - Suffix:
Authorized Official - Credentials:PMHCNS-BC
Authorized Official - Phone:260-969-5583
Mailing Address - Street 1:423 AIRPORT N. OFFICE PARK
Mailing Address - Street 2:
Mailing Address - City:FORT. WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-6704
Mailing Address - Country:US
Mailing Address - Phone:260-969-5583
Mailing Address - Fax:260-969-5584
Practice Address - Street 1:423 AIRPORT N. OFFICE PARK
Practice Address - Street 2:
Practice Address - City:FT. WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-6704
Practice Address - Country:US
Practice Address - Phone:260-969-5583
Practice Address - Fax:260-969-5584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042050A103TH0100X
IN70000153A103TP0016X
IN35001565A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN7585825OtherAETNA
IN376137OtherANTHEM
IN386107OtherANTHEM
INQ27874Medicare UPIN
230270CMedicare ID - Type Unspecified
IN230270AMedicare ID - Type Unspecified