Provider Demographics
NPI:1407848500
Name:GRANT-BLACKFORD MENTAL HEALTH, INC.
Entity Type:Organization
Organization Name:GRANT-BLACKFORD MENTAL HEALTH, INC.
Other - Org Name:RADIANT HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOMINISSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-668-6713
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:765-662-7480
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:765-662-7480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
IN414261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100123170AMedicaid
IN100123170AMedicaid