Provider Demographics
NPI:1164600979
Name:COLES COUNTY MENTAL HEALTH ASSOCIATION, INC.
Entity Type:Organization
Organization Name:COLES COUNTY MENTAL HEALTH ASSOCIATION, INC.
Other - Org Name:COURTYARD SQUARE
Other - Org Type:Other Name
Authorized Official - Title/Position:ACCESS CENTER COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:217-238-5735
Mailing Address - Street 1:750 BROADWAY AVE E
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4610
Mailing Address - Country:US
Mailing Address - Phone:217-238-5700
Mailing Address - Fax:217-238-5767
Practice Address - Street 1:415 18TH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2399
Practice Address - Country:US
Practice Address - Phone:217-238-5700
Practice Address - Fax:217-238-5767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========006Medicaid