Basic Information
| Provider Information | |||||||||
| NPI: | 1063544989 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | QUINCO CONSULTING CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | QUINCO BEHAVIORAL HEALTH SYSTEMS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 N MARR RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472016660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123143400 | ||||||||
| FaxNumber: | 8123788367 | ||||||||
| Practice Location | |||||||||
| Address1: | 299 W HAYDEN PIKE | ||||||||
| Address2: | |||||||||
| City: | NORTH VERNON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123467892 | ||||||||
| FaxNumber: | 8123467301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8123143400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD HSPP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 000000209001 | 01 | IN | ANTHEM GROUP PIN | OTHER |