Provider Demographics
NPI:1376593046
Name:VON BARGEN, WAYNE JAMES (PHD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:JAMES
Last Name:VON BARGEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 SAINT JOE CENTER RD
Mailing Address - Street 2:SUITE 44
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5000
Mailing Address - Country:US
Mailing Address - Phone:260-471-8033
Mailing Address - Fax:260-471-8107
Practice Address - Street 1:1910 SAINT JOE CENTER RD
Practice Address - Street 2:SUITE 44
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5000
Practice Address - Country:US
Practice Address - Phone:260-471-8033
Practice Address - Fax:260-471-8107
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010203A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN667150AMedicare ID - Type Unspecified