Provider Demographics
NPI:1235663949
Name:HERITAGE BEHAVIORAL HEALTH CENTER
Entity Type:Organization
Organization Name:HERITAGE BEHAVIORAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEVENGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-362-6262
Mailing Address - Street 1:151 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62523-1206
Mailing Address - Country:US
Mailing Address - Phone:217-362-6262
Mailing Address - Fax:217-362-6290
Practice Address - Street 1:40 CLINTON PLZ
Practice Address - Street 2:HWY 54
Practice Address - City:CLINTON
Practice Address - State:IL
Practice Address - Zip Code:61727-2100
Practice Address - Country:US
Practice Address - Phone:217-362-6262
Practice Address - Fax:217-362-6290
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE BEHAVIORAL HEALTH CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
969890Medicare PIN