Healthcare Provider Details

I. General information

NPI: 1174078893
Provider Name (Legal Business Name): FONTHILL BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 E KIRKWOOD AVE SUITE 5
BLOOMINGTON IN
47408-3559
US

IV. Provider business mailing address

221 E KIRKWOOD AVE SUITE 5
BLOOMINGTON IN
47408-3559
US

V. Phone/Fax

Practice location:
  • Phone: 812-727-0722
  • Fax:
Mailing address:
  • Phone: 812-727-0722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. ROB DANZMAN
Title or Position: CLINICAL DIRECTOR
Credential: NCC, LPC
Phone: 812-727-0722