Provider Demographics
NPI:1740489939
Name:SOUTH BEND MENTAL HEALTH ASSOCIATES, PC
Entity type:Organization
Organization Name:SOUTH BEND MENTAL HEALTH ASSOCIATES, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:WAX
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:574-255-1162
Mailing Address - Street 1:113 LINCOLN WAY E
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2016
Mailing Address - Country:US
Mailing Address - Phone:574-255-1162
Mailing Address - Fax:574-233-8002
Practice Address - Street 1:113 LINCOLN WAY E
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2016
Practice Address - Country:US
Practice Address - Phone:574-255-1162
Practice Address - Fax:574-233-8002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN57000133A103T00000X, 103TC0700X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000368604OtherANTHEM
IN200021670Medicaid