Healthcare Provider Details

I. General information

NPI: 1235527524
Provider Name (Legal Business Name): HERITAGE BEHAVIORAL HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2015
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 W PRAIRIE AVE
DECATUR IL
62522-2444
US

IV. Provider business mailing address

151 N MAIN ST
DECATUR IL
62523
US

V. Phone/Fax

Practice location:
  • Phone: 217-423-0548
  • Fax: 217-632-6290
Mailing address:
  • Phone: 217-362-6262
  • Fax: 217-362-6290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number04070
License Number StateIL

VIII. Authorized Official

Name: MARY GARRISON
Title or Position: PRESIDENT/CEO
Credential: LCSW
Phone: 217-362-6262