Organization
NORTHEASTERN CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JERRY HOLLISTER (CEO)
(260) 347-2453
Entity
Organization
Contact information
Practice address
220 S MAIN ST, KENDALLVILLE, IN 46755-1718
(260) 347-2453
(260) 347-2456
Mailing address
PO BOX 817, KENDALLVILLE, IN 46755-0817
(260) 347-2453
(260) 347-2456
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
426-0-CMHC
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100190820M
—
IN
Enumeration date
12/18/2006
Last updated
06/16/2008
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