Basic Information
| Provider Information | |||||||||
| NPI: | 1659302461 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CHILDREN'S CAMPUS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1411 LINCOLN WAY W | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465441626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742595666 | ||||||||
| FaxNumber: | 5742556179 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 LINCOLN WAY W | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465441626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742595666 | ||||||||
| FaxNumber: | 5742556179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ERMETI | ||||||||
| AuthorizedOfficialFirstName: | KRISTIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5742595666 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.S.W, L.C.S.W. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 43714 | IN | X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 320800000X | 43486 | IN | X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 320800000X | 43738 | IN | X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 320800000X | 42256 | IN | X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 322D00000X | 32231 | IN | X | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 323P00000X | 73718 | IN | X | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
No ID Information.