Provider Demographics
NPI:1134630387
Name:SALLAZ, CATHERINE (MHC)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:SALLAZ
Suffix:
Gender:F
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 MALLARD COVE LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2882
Mailing Address - Country:US
Mailing Address - Phone:260-459-6095
Mailing Address - Fax:
Practice Address - Street 1:3120 MALLARD COVE LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2882
Practice Address - Country:US
Practice Address - Phone:260-459-6095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002872A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty