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9025 Coldwater Rd Ste 100 Fort Wayne IN 46825-2071 | |
| (260) 459-9225 | |
| (260) 800-1512 |
| Full Name | |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 9025 Coldwater Rd Ste 100, Fort Wayne, Indiana |
| Authorized Official Name and Position | Sean Goddard (OWNER) |
| Authorized Official Contact | 2604599225 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
9025 Coldwater Rd Ste 100 Fort Wayne IN 46825-2071 Ph: (260) 459-9225 | 9025 Coldwater Rd Ste 100 Fort Wayne IN 46825-2071 Ph: (260) 459-9225 |
| NPI Number | 1184292054 |
|---|---|
| Provider Enumeration Date | 06/16/2021 |
| Last Update Date | 09/26/2024 |
| Certification Date | 09/26/2024 |
| Medicare PECOS PAC ID | 4385093350 |
|---|---|
| Medicare Enrollment ID | O20231215002045 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1184292054 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0800X | Psychiatry & Neurology - Psychiatry | (* (Not Available)) | Primary |
| Provider Name | Andrea Hiyam Naaum |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1487071809 PECOS PAC ID: 0143510248 Enrollment ID: I20180810000287 |
| Provider Name | Valerie J Rumple |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1174706691 PECOS PAC ID: 7012260185 Enrollment ID: I20181019002049 |
| Provider Name | Sean Goddard |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1285117143 PECOS PAC ID: 5294088670 Enrollment ID: I20181101001078 |
| Provider Name | Victoria Ong-murrell |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1205515244 PECOS PAC ID: 4486016078 Enrollment ID: I20230814002974 |
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