Healthcare Provider Details

I. General information

NPI: 1619280153
Provider Name (Legal Business Name): UHS MIDWEST CENTER FOR YOUTH & FAMILIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 W. INDIANA ST
KOUTS IN
46347-9703
US

IV. Provider business mailing address

P.O. BOX 669 1012 W. INDIANA ST
KOUTS IN
46347-9703
US

V. Phone/Fax

Practice location:
  • Phone: 219-766-2999
  • Fax: 219-766-2704
Mailing address:
  • Phone: 219-766-2999
  • Fax: 219-766-2704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5180909873540
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number73540
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5180909873540
License Number StateIN

VIII. Authorized Official

Name: MR. MICHAEL JOHN PERRY
Title or Position: CEO
Credential:
Phone: 219-766-2999