Provider Demographics
NPI:1972769735
Name:BARTA, MARY LISA (MS, LMFTA)
Entity Type:Individual
Prefix:MRS
First Name:MARY LISA
Middle Name:
Last Name:BARTA
Suffix:
Gender:F
Credentials:MS, LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10315E DAWSON'S CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1721
Mailing Address - Country:US
Mailing Address - Phone:260-387-6340
Mailing Address - Fax:
Practice Address - Street 1:10315E DAWSON'S CREEK BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1721
Practice Address - Country:US
Practice Address - Phone:260-387-6340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001710106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
472786292OtherTIN