Provider Demographics
NPI:1407216252
Name:CHRISTIAN COUNTY MENTAL HEALTH ASSOCIATION
Entity Type:Organization
Organization Name:CHRISTIAN COUNTY MENTAL HEALTH ASSOCIATION
Other - Org Name:CCMHA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-824-4905
Mailing Address - Street 1:PO BOX 438
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-0438
Mailing Address - Country:US
Mailing Address - Phone:217-824-4905
Mailing Address - Fax:217-824-3570
Practice Address - Street 1:703 MCADAM DR
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-2300
Practice Address - Country:US
Practice Address - Phone:217-824-4905
Practice Address - Fax:217-824-3570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04025Medicaid
IL727570Medicare UPIN