Impact Behavioral Services LLC

Primary specialty

Community/Behavioral Health AgencyTaxonomy code 251S00000X

Legal business name

IMPACT BEHAVIORAL SERVICES LLC

Practice address

4606 E State Blvd
Fort Wayne, IN 46815-6993

Phone

(260) 740-5139

NPI assigned

Jun 15, 2022

Last updated

Jun 15, 2022By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Shawn A Wallace, MS

Title

Owner

Phone

(260) 740-5139

Specialties & licenses 1

Addresses

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

{
    "created_epoch": "1655251200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1655251200000",
    "number": "1265162846",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2918 ELMWOOD CT",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468046100",
            "telephone_number": "260-740-5139"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4606 E STATE BLVD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468156993",
            "telephone_number": "260-740-5139"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMPACT BEHAVIORAL SERVICES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-06-15",
        "last_updated": "2022-06-15",
        "certification_date": "2022-06-15",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "SHAWN",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "260-740-5139",
        "authorized_official_credential": "MS"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 15, 2022; 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.