Healthcare Provider Details

I. General information

NPI: 1568311900
Provider Name (Legal Business Name): ICR OUTPATIENT OPERATING SUBSIDIARY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2026
Last Update Date: 07/26/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 HOSPITAL LN
TERRE HAUTE IN
47802-4247
US

IV. Provider business mailing address

2925 10TH AVE N
PALM SPRINGS FL
33461-3000
US

V. Phone/Fax

Practice location:
  • Phone: 812-645-3895
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: TARA GURNEY
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 561-517-3400