Provider Demographics
NPI:1154788032
Name:MAINSTAY MUSIC THERAPY, INC
Entity type:Organization
Organization Name:MAINSTAY MUSIC THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MT-BC
Authorized Official - Phone:260-494-1624
Mailing Address - Street 1:1910 SAINT JOE CENTER RD STE 44
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5000
Mailing Address - Country:US
Mailing Address - Phone:260-494-1624
Mailing Address - Fax:260-494-1624
Practice Address - Street 1:10812 COLDWATER RD STE 400
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1204
Practice Address - Country:US
Practice Address - Phone:260-409-8246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-22
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201028040 AOtherMEDICAID WAIVER LEGACY NUMBER