Provider Demographics
NPI:1477603538
Name:PROVIDENCE HOUSE
Entity type:Organization
Organization Name:PROVIDENCE HOUSE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:PORTER
Authorized Official - Last Name:ENGLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, HSPP
Authorized Official - Phone:502-224-0789
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?:Yes
Parent Organization LBN:PROVIDENCE SELF SUFFICIENCY MINISTRIES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-11
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental IllnessGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200358070Medicaid