Provider Demographics
NPI:1811025240
Name:MOULTRIE COUNTY MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:MOULTRIE COUNTY MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:217-728-4358
Mailing Address - Street 1:12 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IL
Mailing Address - Zip Code:61951-1907
Mailing Address - Country:US
Mailing Address - Phone:217-728-4358
Mailing Address - Fax:217-728-2270
Practice Address - Street 1:12 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IL
Practice Address - Zip Code:61951-1907
Practice Address - Country:US
Practice Address - Phone:217-728-4358
Practice Address - Fax:217-728-2270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0043-0002-A101YA0400X
IL04105101YM0800X, 251S00000X
IL180.005810101YP2500X
IL178.004724101YP2500X
IL180.003537101YP2500X
IL149.0110511041C0700X
IL36052881261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360458Medicare ID - Type UnspecifiedFOR ROHI PATIL, MD