1972545945 NPI number — FOUR COUNTY COMPREHENSIVE MENTAL HEALTH CENTER INC

Table of content: (NPI 1972545945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972545945 NPI number — FOUR COUNTY COMPREHENSIVE MENTAL HEALTH CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUR COUNTY COMPREHENSIVE MENTAL HEALTH CENTER INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FOUR COUNTY COUNSELING CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972545945
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 FULTON ST
Provider Second Line Business Mailing Address:
C/O JASON CADWELL
Provider Business Mailing Address City Name:
LOGANSPORT
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46947-1577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-722-5151
Provider Business Mailing Address Fax Number:
574-739-1414

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1015 MICHIGAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46947-1527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-722-5151
Provider Business Practice Location Address Fax Number:
574-739-1414
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CADWELL
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
574-722-5151

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  427-0-CMHC , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0400X , with the licence number: 427-0-CMHC , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100464740 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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