Provider Demographics
NPI:1972545945
Name:FOUR COUNTY COMPREHENSIVE MENTAL HEALTH CENTER INC
Entity type:Organization
Organization Name:FOUR COUNTY COMPREHENSIVE MENTAL HEALTH CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CADWELL
Authorized Official - Suffix:
Authorized Official - Credentials:HSPP
Authorized Official - Phone:574-722-5151
Mailing Address - Street 1:2355 S BUSINESS 31
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-8985
Mailing Address - Country:US
Mailing Address - Phone:574-722-5151
Mailing Address - Fax:574-739-1414
Practice Address - Street 1:1000 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1070
Practice Address - Country:US
Practice Address - Phone:574-722-5151
Practice Address - Fax:574-739-1414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN427-0-CMHC261QM0801X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100464740Medicaid
IN111810Medicare PIN