Provider Demographics
NPI:1043414428
Name:NORTHEASTERN CENTER,INC
Entity Type:Organization
Organization Name:NORTHEASTERN CENTER,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AREA DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMARA
Authorized Official - Suffix:
Authorized Official - Credentials:MA,CRC,LPC
Authorized Official - Phone:1260-347-4400
Mailing Address - Street 1:1930 DOWLING ST
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-9436
Mailing Address - Country:US
Mailing Address - Phone:126-034-7440
Mailing Address - Fax:126-034-7312
Practice Address - Street 1:1930 DOWLING ST
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-9436
Practice Address - Country:US
Practice Address - Phone:126-034-7440
Practice Address - Fax:126-034-7312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101YM0800X302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization