Healthcare Provider Details

I. General information

NPI: 1245302934
Provider Name (Legal Business Name): FAMILY PSYCHIATRIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 W ALTO RD
KOKOMO IN
46902-4907
US

IV. Provider business mailing address

PO BOX 6459
KOKOMO IN
46904-6459
US

V. Phone/Fax

Practice location:
  • Phone: 765-453-7422
  • Fax: 765-453-3773
Mailing address:
  • Phone: 765-453-7422
  • Fax: 765-453-3773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number28095903A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20010245
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01023409
License Number StateIN

VIII. Authorized Official

Name: MR. DONALD L ROEGNER JR.
Title or Position: M.D. DBA
Credential: M.D
Phone: 765-453-7422