Basic Information
| Provider Information | |||||||||
| NPI: | 1053763250 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLES COUNTY MENTAL HEALTH ASSOCIATION, INC. | ||||||||
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| OtherOrganizationName: | LIFELINKS MENTAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 BROADWAY AVE E | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172385700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 626 W LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619202444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172385700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2016 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | SOWERS | ||||||||
| AuthorizedOfficialFirstName: | ANGIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ACCESS CENTER COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2172385700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | B.A. | ||||||||
| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.