Healthcare Provider Details

I. General information

NPI: 1942203914
Provider Name (Legal Business Name): COLES COUNTY MENTAL HEALTH ASSOCIATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 BROADWAY AVE E
MATTOON IL
61938-4610
US

IV. Provider business mailing address

750 BROADWAY AVE E
MATTOON IL
61938-4610
US

V. Phone/Fax

Practice location:
  • Phone: 217-238-5700
  • Fax: 217-238-5767
Mailing address:
  • Phone: 217-238-5700
  • Fax: 217-238-5767

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 Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH KING
Title or Position: EXECUTIVE DIRECTOR
Credential: LCPC
Phone: 217-238-5700