Provider Demographics
NPI:1053665158
Name:CORNERSTONE
Entity Type:Organization
Organization Name:CORNERSTONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KUCZORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-662-3971
Mailing Address - Street 1:505 N WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2608
Mailing Address - Country:US
Mailing Address - Phone:765-662-3971
Mailing Address - Fax:
Practice Address - Street 1:505 N WABASH AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2608
Practice Address - Country:US
Practice Address - Phone:765-662-3971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANT BLACKFORD MENTAL HELTH, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006590A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health