Provider Demographics
NPI:1558025734
Name:PWA & SPENCER HOME LLC
Entity type:Organization
Organization Name:PWA & SPENCER HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE & CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:KOLBY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-702-3640
Mailing Address - Street 1:4150 ILLINOIS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1208
Mailing Address - Country:US
Mailing Address - Phone:260-702-3640
Mailing Address - Fax:866-681-7794
Practice Address - Street 1:27 PEQUIGNOT DR
Practice Address - Street 2:
Practice Address - City:PIERCETON
Practice Address - State:IN
Practice Address - Zip Code:46562-9081
Practice Address - Country:US
Practice Address - Phone:260-702-3752
Practice Address - Fax:866-681-7794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-25
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty