Provider Demographics
NPI:1992781470
Name:CENTERSTONE OF INDIANA, INC.
Entity type:Organization
Organization Name:CENTERSTONE OF INDIANA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:KOESEL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:812-337-2350
Mailing Address - Street 1:645 S ROGERS STREET
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:812-337-2438
Practice Address - Street 1:645 S ROGERS ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403
Practice Address - Country:US
Practice Address - Phone:812-339-1691
Practice Address - Fax:812-337-2438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 261QM0801X
IN431-049324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100182650Medicaid
IN541910Medicare PIN