Provider Demographics
NPI:1457539751
Name:FOUR COUNTY COMPREHENSIVE MENTAL HEALTH CENTER, INC
Entity Type:Organization
Organization Name:FOUR COUNTY COMPREHENSIVE MENTAL HEALTH CENTER, INC
Other - Org Name:FOUR COUNTY COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:PSYD
Authorized Official - Phone:574-722-5151
Mailing Address - Street 1:800 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1577
Mailing Address - Country:US
Mailing Address - Phone:574-722-5151
Mailing Address - Fax:574-739-1414
Practice Address - Street 1:1015 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1526
Practice Address - Country:US
Practice Address - Phone:574-722-5151
Practice Address - Fax:574-739-1414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN427-1-PIP283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100273560Medicaid
IN154035Medicare Oscar/Certification