Provider Demographics
NPI:1104609544
Name:HERITAGE BEHAVIORAL HEALTH CENTER INC.
Entity type:Organization
Organization Name:HERITAGE BEHAVIORAL HEALTH CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:217-362-6262
Mailing Address - Street 1:151 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62523-1206
Mailing Address - Country:US
Mailing Address - Phone:217-362-6262
Mailing Address - Fax:
Practice Address - Street 1:243 W CERRO GORDO ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62522-2101
Practice Address - Country:US
Practice Address - Phone:217-422-3940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty