Provider Demographics
NPI:1558441063
Name:PSYCHOLOGICAL SERVICE ASSOCIATES, INC
Entity Type:Organization
Organization Name:PSYCHOLOGICAL SERVICE ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERE
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEIB
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:260-482-8427
Mailing Address - Street 1:3421 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4830
Mailing Address - Country:US
Mailing Address - Phone:260-482-8427
Mailing Address - Fax:260-482-8429
Practice Address - Street 1:3421 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4830
Practice Address - Country:US
Practice Address - Phone:260-482-8427
Practice Address - Fax:260-482-8429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN103T00000X, 103TA0700X, 103TB0200X, 103TC0700X, 103TC2200X, 103TF0000X, 103TF0200X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Single Specialty
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Single Specialty
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Single Specialty
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000176183OtherBCBS GROUP
IN218190Medicare ID - Type Unspecified