Individual
JOHN M MUSGRAVE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PSY.D
Contact information
Practice address
3470 STELLHORN RD, FORT WAYNE, IN 46815-4630
(260) 385-1646
Mailing address
6435 W JEFFERSON BLVD, PMB 145, FORT WAYNE, IN 46804-6203
(260) 385-1646
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
20041940A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000543924
ANTHEM
IN
05
—
200403270
—
IN
Enumeration date
08/18/2005
Last updated
05/19/2008
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