Provider Demographics
NPI:1922497775
Name:MARY LISA BARTA LLC
Entity Type:Organization
Organization Name:MARY LISA BARTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-471-1662
Mailing Address - Street 1:5630 THE PROPHETS PASS
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9473
Mailing Address - Country:US
Mailing Address - Phone:260-471-1662
Mailing Address - Fax:
Practice Address - Street 1:5630 THE PROPHETS PASS
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-9473
Practice Address - Country:US
Practice Address - Phone:260-471-1662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001710A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty