Healthcare Provider Details

I. General information

NPI: 1972545945
Provider Name (Legal Business Name): FOUR COUNTY COMPREHENSIVE MENTAL HEALTH CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N BROADWAY
PERU IN
46970-1070
US

IV. Provider business mailing address

2355 S BUSINESS 31
PERU IN
46970-8985
US

V. Phone/Fax

Practice location:
  • Phone: 574-722-5151
  • Fax: 574-739-1414
Mailing address:
  • Phone: 574-722-5151
  • Fax: 574-739-1414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number427-0-CMHC
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number427-0-CMHC
License Number StateIN

VIII. Authorized Official

Name: CARRIE ANN CADWELL
Title or Position: CEO
Credential: HSPP
Phone: 574-722-5151