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NPI Code Detail

MEDICARE: COLES COUNTY MENTAL HEALTH ASSOCIATION, INC.

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
1261QR0405XSubstance Use Disorder Rehabilitation Clinic/Center
2261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number : 1942203914
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 : 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
Authorized Official
Title or Position : EXECUTIVE DIRECTOR
Name : MR. JOSEPH KING
Credential : LCPC
Telephone Number : 217-238-5700
Provider Enumeration Date : 05/24/2005
Last Update Date : 03/13/2023

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1073625042 — MRS. BARBARA E ESTES M.S.
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