Provider Demographics
NPI:1770709230
Name:AMETHYST HOUSE, INC.
Entity type:Organization
Organization Name:AMETHYST HOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DELONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-336-3570
Mailing Address - Street 1:PO BOX 11
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-0011
Mailing Address - Country:US
Mailing Address - Phone:812-336-3570
Mailing Address - Fax:812-336-9010
Practice Address - Street 1:645 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3846
Practice Address - Country:US
Practice Address - Phone:812-336-3570
Practice Address - Fax:812-336-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1279-0 ASR251S00000X
IN1279-0 CA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251S00000XAgenciesCommunity/Behavioral Health