Provider Demographics
NPI:1336190149
Name:MIDWEST ADDICTION PSYCHIATRIC & PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:MIDWEST ADDICTION PSYCHIATRIC & PSYCHOLOGICAL SERVICES LLC
Other - Org Name:MAPPS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DON
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:260-456-7261
Mailing Address - Street 1:3010 E STATE BLVD
Mailing Address - Street 2:SUTIE A
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4700
Mailing Address - Country:US
Mailing Address - Phone:260-471-0632
Mailing Address - Fax:260-471-3451
Practice Address - Street 1:3010 E. STATE BLVD
Practice Address - Street 2:STE 100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805
Practice Address - Country:US
Practice Address - Phone:260-471-0632
Practice Address - Fax:260-471-3451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN14060ASO101YA0400X, 101YM0800X, 103T00000X, 103TA0400X, 103TB0200X, 103TC2200X, 103TF0200X, 1041C0700X, 106H00000X, 2084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200200260AMedicaid