MEDICARE: COLES COUNTY MENTAL HEALTH ASSOCIATION, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1548448913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLES COUNTY MENTAL HEALTH ASSOCIATION, INC.

Provider Business Mailing Address
First Line	:	750 BROADWAY AVE E
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-4610
Country	:	US
Telephone Number	:	217-238-5700
Fax Number	:	217-238-5767

Provider Business Practice Location Address
First Line	:	1504 20TH ST
Second Line	:
City	:	CHARLESTON
State	:	IL
Zip	:	61920-3615
Country	:	US
Telephone Number	:	217-238-5700
Fax Number	:	217-238-5767

Authorized Official
Title or Position	:	ACCESS CENTER COORDINATOR
Name	:	ANGIE SOWERS
Credential	:	B.A.
Telephone Number	:	217-238-5735

Provider Enumeration Date	:	02/07/2008
Last Update Date	:	04/25/2017

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