Basic Information
Provider Information | |||||||||
NPI: | 1134118276 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHERN HILLS COUNSELING CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 769 | ||||||||
Address2: |   | ||||||||
City: | JASPER | ||||||||
State: | IN | ||||||||
PostalCode: | 475470769 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124823020 | ||||||||
FaxNumber: | 8124826409 | ||||||||
Practice Location | |||||||||
Address1: | 480 EVERSMAN DR | ||||||||
Address2: |   | ||||||||
City: | JASPER | ||||||||
State: | IN | ||||||||
PostalCode: | 475463548 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124823020 | ||||||||
FaxNumber: | 8124826409 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2005 | ||||||||
LastUpdateDate: | 10/30/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WHITAKER | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: | KENT | ||||||||
AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR/CFO | ||||||||
AuthorizedOfficialTelephone: | 8124823020 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: | PH. D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2084P0800X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 103TC0700X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 100108710 | 05 | IN |   | MEDICAID |