Healthcare Provider Details

I. General information

NPI: 1659544872
Provider Name (Legal Business Name): HERITAGE BEHAVIORAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 09/18/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 E CARRIE LANE
DECATUR IL
62526
US

IV. Provider business mailing address

PO BOX 710
DECATUR IL
62525-0710
US

V. Phone/Fax

Practice location:
  • Phone: 217-421-7297
  • Fax: 217-362-6290
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 Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberT
License Number StateIL

VIII. Authorized Official

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