NPIMap

Organization Active NPI

Fort Wayne Neuropsychology LLC

  • Clinical Neuropsychologist
  • Fort Wayne, IN
National Provider Identifier
1871032862
Registry record updated Feb 23, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical NeuropsychologistTaxonomy code 103G00000X
Legal business name
FORT WAYNE NEUROPSYCHOLOGY LLC
Practice address
4306 E State Blvd
Fort Wayne, IN 46815-6915
Phone
(260) 460-3100
NPI assigned
Feb 23, 2017
Last updated
Feb 23, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 23, 2017

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

Authorized official

Name
Tasha H. Williams, PH.D.NPI 1467499780
Title
Vice President
Phone
(260) 414-8629

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 3

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Neuropsychologist 103G00000X NU Primary
Psychologist 103T00000X NU
Clinical Social Worker 1041C0700X NU

Addresses

Primary practice location

4306 E State Blvd
Fort Wayne, IN 46815-6915

Mailing address

4306 E State Blvd
Fort Wayne, IN 46815-6915

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170417001683 IN Part B Supplier - Clinic/Group Practice 0345526893 Receives reassigned benefits from 9 practitioners
Practice locations: Fort Wayne, IN; Warsaw, IN

National Provider Directory

National Provider Directory

Locations

7956 W Jefferson Blvd
Ste 220
Fort Wayne, IN 46804
Phone (260) 406-3203

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1487808000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1487808000000",
    "number": "1871032862",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4306 E STATE BLVD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468156915"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4306 E STATE BLVD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468156915",
            "telephone_number": "260-460-3100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORT WAYNE NEUROPSYCHOLOGY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-02-23",
        "last_updated": "2017-02-23",
        "status": "A",
        "authorized_official_last_name": "WILLIAMS",
        "authorized_official_first_name": "TASHA",
        "authorized_official_middle_name": "H.",
        "authorized_official_title_or_position": "VICE PRESIDENT",
        "authorized_official_telephone_number": "260-414-8629",
        "authorized_official_credential": "PH.D."
    },
    "taxonomies": [
        {
            "code": "103G00000X",
            "taxonomy_group": "",
            "desc": "Clinical Neuropsychologist",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Wayne, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 23, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.