Basic Information
| Provider Information | |||||||||
| NPI: | 1881132397 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLES COUNTY MENTAL HEALTH ASSOCIATION | ||||||||
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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 | ||||||||
| FaxNumber: | 2172385767 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 BROADWAY AVE E | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172385700 | ||||||||
| FaxNumber: | 2172385767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2017 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | ASHMORE | ||||||||
| AuthorizedOfficialFirstName: | LYNETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2172385700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.