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General NPI Number Information
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NPI Number | 1821540865
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Entity Type | Organization
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Legal Business Name | HERITAGE BEHAVIORAL HEALTH CENTER
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Dates
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Enumeration Date | 10/25/2016
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Last Update Date | 12/14/2016
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Provider Practice Location Address
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Address Line | 1029 N WATER ST
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City | DECATUR
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State | IL
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Zip | 62523-1022
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Country | US
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Telephone | 217-362-6262
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Fax | 217-362-6290
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Provider Business Mailing Address
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Address Line | 151 N MAIN ST
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City | DECATUR
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State | IL
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Zip | 62523-1206
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Country | US
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Telephone | 217-362-6262
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Fax | 217-362-6290
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | CANDACE CLEVENGER
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Credential |
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Telephone | 217-362-6262
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | A-0200-0004-A
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License Number State | IL
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