1700932233 NPI number — GRANT-BLACKFORD MENTAL HEALTH, INC.

Table of content: (NPI 1700932233)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700932233 NPI number — GRANT-BLACKFORD MENTAL HEALTH, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANT-BLACKFORD MENTAL HEALTH, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RADIANT HEALTH SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700932233
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 N WABASH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46952-2608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-662-3971
Provider Business Mailing Address Fax Number:
765-662-7480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 W 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46953-1921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-664-7792
Provider Business Practice Location Address Fax Number:
765-662-7480
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DOMINISSE
Authorized Official First Name:
LISA
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
765-668-6713

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  414-0-CMHC , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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