Provider Demographics
NPI:1477603538
Name:PROVIDENCE SELF SUFFICIENCY MINISTRIES
Entity Type:Organization
Organization Name:PROVIDENCE SELF SUFFICIENCY MINISTRIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-951-1878
Mailing Address - Street 1:8037 UNRUH DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47122-8759
Mailing Address - Country:US
Mailing Address - Phone:812-951-1878
Mailing Address - Fax:812-951-0398
Practice Address - Street 1:8037 UNRUH DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:IN
Practice Address - Zip Code:47122-8759
Practice Address - Country:US
Practice Address - Phone:812-951-1878
Practice Address - Fax:812-951-0398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200358070Medicaid