Provider Demographics
NPI:1992974620
Name:INDIANA PROFESSIONAL PSYCHOLOGICAL SERVICES, P.C.
Entity type:Organization
Organization Name:INDIANA PROFESSIONAL PSYCHOLOGICAL SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST, PRESIDENT IPPS
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BANEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:260-469-0090
Mailing Address - Street 1:6408 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1558
Mailing Address - Country:US
Mailing Address - Phone:260-469-0090
Mailing Address - Fax:260-469-0091
Practice Address - Street 1:6408 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1558
Practice Address - Country:US
Practice Address - Phone:260-469-0090
Practice Address - Fax:260-469-0091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040759A103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
200450OtherMEDICARE
200450Medicare PIN