NPIMap

Organization Active NPI

Family Psychology of South Bend LLC

  • Family Psychologist
  • South Bend, IN
National Provider Identifier
1083184196
Registry record updated Dec 1, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family PsychologistTaxonomy code 103TF0000X
Legal business name
FAMILY PSYCHOLOGY OF SOUTH BEND LLC
Practice address
922 E Wayne St Ste 205
South Bend, IN 46617-3024
Phone
(574) 280-8199
NPI assigned
Dec 1, 2018
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 1, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
John Anthony Petersen, PSYDNPI 1851491526
Title
Manager
Phone
(574) 280-8199

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YM0800X
Clinical PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC0700X
Family PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TF0000X Primary
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X

Addresses

Primary practice location

922 E Wayne St Ste 205
South Bend, IN 46617-3024

Mailing address

922 E Wayne St Ste 205
South Bend, IN 46617-3024
Phone (574) 280-8199

Other practice location 1

115 S Saint Peter St
South Bend, IN 46617-2912
Phone (574) 280-8199 ext. 2

Other names 1

  • Family Psychology of South Bend Doing business as

National Provider Directory

National Provider Directory

Locations

115 S Saint Peter St
South Bend, IN 46617
Phone (574) 280-8199

922 E Wayne St
Ste 205
South Bend, IN 46617
Phone (574) 280-8199

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1543622400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1543622400000",
    "number": "1083184196",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "922 E WAYNE ST STE 205",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466173024",
            "telephone_number": "574-280-8199"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "922 E WAYNE ST STE 205",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466173024",
            "telephone_number": "574-280-8199"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "115 S Saint Peter St",
            "address_purpose": "LOCATION",
            "city": "South Bend",
            "state": "IN",
            "postal_code": "466172912",
            "country_code": "US",
            "telephone_number": "574-280-8199 x2",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "FAMILY PSYCHOLOGY OF SOUTH BEND LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-12-01",
        "last_updated": "2018-12-01",
        "status": "A",
        "authorized_official_last_name": "PETERSEN",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "ANTHONY",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "574-280-8199",
        "authorized_official_credential": "PSYD"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Family",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Family Psychology of South Bend",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in South Bend, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 1, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.