Healthcare Provider Details

I. General information

NPI: 1104609544
Provider Name (Legal Business Name): HERITAGE BEHAVIORAL HEALTH CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 W CERRO GORDO ST
DECATUR IL
62522-2101
US

IV. Provider business mailing address

151 N MAIN ST
DECATUR IL
62523-1206
US

V. Phone/Fax

Practice location:
  • Phone: 217-422-3940
  • Fax:
Mailing address:
  • Phone: 217-362-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

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