Provider Demographics
NPI:1508196494
Name:HERITAGE BEHAVIORAL HEALTH CENTER
Entity Type:Organization
Organization Name:HERITAGE BEHAVIORAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:VANDYKE
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 1:151 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62523-1206
Practice Address - Country:US
Practice Address - Phone:217-362-6262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-28
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0200-002-A251S00000X, 261QM2800X
ILA-0200-001-A324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid
969890Medicare PIN