Provider Demographics
NPI:1699868893
Name:CROSSROAD CHILD & FAMILY SERVICES, INC.
Entity type:Organization
Organization Name:CROSSROAD CHILD & FAMILY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-484-4153
Mailing Address - Street 1:1825 BEACON STREET
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805
Mailing Address - Country:US
Mailing Address - Phone:260-484-4153
Mailing Address - Fax:260-484-2337
Practice Address - Street 1:1825 BEACON STREET
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805
Practice Address - Country:US
Practice Address - Phone:260-484-4153
Practice Address - Fax:260-484-2337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN3001702900002322D00000X, 323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200295210Medicaid