=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245497213
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMARITAN BEHAVIORAL HEALTHCARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2008
-----------------------------------------------------
Last Update Date | 04/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 969 W MCCLAIN AVE SUITE B
-----------------------------------------------------
City | SCOTTSBURG
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-754-1660
-----------------------------------------------------
Fax | 812-754-1664
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 462 P.O. BOX 462
-----------------------------------------------------
City | SCOTTSBURG
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-754-1660
-----------------------------------------------------
Fax | 812-754-1664
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO AND PRESIDENT
-----------------------------------------------------
Name | DR. DONE KRISTEN SMALL
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 812-754-1660
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 39000208A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------