Provider Demographics
NPI:1417663295
Name:CLINICAL FAMILY SERVICES LLC
Entity Type:Organization
Organization Name:CLINICAL FAMILY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:317-919-0093
Mailing Address - Street 1:1404 KIMMELL ROAD
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591
Mailing Address - Country:US
Mailing Address - Phone:317-919-0093
Mailing Address - Fax:
Practice Address - Street 1:1404 KIMMELL ROAD
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591
Practice Address - Country:US
Practice Address - Phone:317-919-0093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100133060Medicaid