Healthcare Provider Details

I. General information

NPI: 1477603538
Provider Name (Legal Business Name): PROVIDENCE HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 08/22/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8037 UNRUH DR
GEORGETOWN IN
47122-8759
US

IV. Provider business mailing address

8037 UNRUH DR
GEORGETOWN IN
47122-8759
US

V. Phone/Fax

Practice location:
  • Phone: 812-951-1878
  • Fax: 812-951-0398
Mailing address:
  • Phone: 812-951-1878
  • Fax: 812-951-0398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH PORTER ENGLAND
Title or Position: EXECUTIVE DIRECTOR
Credential: PSYD, HSPP
Phone: 502-224-0789