Provider Demographics
NPI:1447391495
Name:FAMILY AND CHILDREN BEHAVIORAL HEALTH PC
Entity Type:Organization
Organization Name:FAMILY AND CHILDREN BEHAVIORAL HEALTH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SYED
Authorized Official - Middle Name:RASHID
Authorized Official - Last Name:MUMTAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-436-0950
Mailing Address - Street 1:4656 W JEFFERSON BLVD
Mailing Address - Street 2:STE. 135
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6857
Mailing Address - Country:US
Mailing Address - Phone:260-436-0959
Mailing Address - Fax:260-436-0893
Practice Address - Street 1:4656 W JEFFERSON BLVD
Practice Address - Street 2:STE. 135
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6857
Practice Address - Country:US
Practice Address - Phone:260-436-0959
Practice Address - Fax:260-436-0893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50004594A261QM0801X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN216550Medicare ID - Type Unspecified