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505 N Wabash Ave Marion IN 46952-2608 | |
| (765) 662-3971 | |
| (765) 662-7480 |
| Full Name | |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 505 N Wabash Ave, Marion, Indiana |
| Authorized Official Name and Position | Lisa A. Dominisse (CEO) |
| Authorized Official Contact | 7656686713 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
505 N Wabash Ave Marion IN 46952-2608 Ph: (765) 662-3971 | 505 N Wabash Ave Marion IN 46952-2608 Ph: (765) 662-3971 |
| NPI Number | 1407848500 |
|---|---|
| Provider Enumeration Date | 08/16/2005 |
| Last Update Date | 09/08/2023 |
| Certification Date | 09/08/2023 |
| Medicare PECOS PAC ID | 9739177528 |
|---|---|
| Medicare Enrollment ID | O20040607001089 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1407848500 | NPI | - | NPPES |
| 100123170A | Medicaid | IN |
| Provider Name | Jerry Dee Havens |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1073566998 PECOS PAC ID: 1456340355 Enrollment ID: I20040506001560 |
| Provider Name | Tricia R Blakely |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1518097559 PECOS PAC ID: 5193792224 Enrollment ID: I20040916000664 |
| Provider Name | Ajanta Goswami |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1407820392 PECOS PAC ID: 3870536493 Enrollment ID: I20050606000331 |
| Provider Name | Sheri L Proffitt |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1033341219 PECOS PAC ID: 2365597515 Enrollment ID: I20090911000353 |
| Provider Name | Michael H Conn |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1932158193 PECOS PAC ID: 6406027440 Enrollment ID: I20110922000389 |
| Provider Name | Arthur Kupersmith |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1861505059 PECOS PAC ID: 5193998623 Enrollment ID: I20111028000495 |
| Provider Name | Avelina T Vitug |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1417061284 PECOS PAC ID: 4981888591 Enrollment ID: I20150810001950 |
| Provider Name | Thomasina Marie Wrangham |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1013340066 PECOS PAC ID: 6800105602 Enrollment ID: I20151019000386 |
| Provider Name | Tammy Conn |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1730622721 PECOS PAC ID: 9638452691 Enrollment ID: I20170217000064 |
| Provider Name | Kelly J Barsha |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1629636832 PECOS PAC ID: 7719211093 Enrollment ID: I20190619002610 |
| Provider Name | Daniel Clayton Brewer |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1205497401 PECOS PAC ID: 2860720745 Enrollment ID: I20190830000869 |
| Provider Name | Hallie K Harris |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1548810047 PECOS PAC ID: 6507197688 Enrollment ID: I20191004001044 |
| Provider Name | Patrick Murathimi Mutugu |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1588205231 PECOS PAC ID: 3678907581 Enrollment ID: I20191231002502 |
| Provider Name | Eduardo V Pereira |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1528117769 PECOS PAC ID: 0244617926 Enrollment ID: I20220518002342 |
| Provider Name | Robbillie Stevenson |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1154971919 PECOS PAC ID: 1052778016 Enrollment ID: I20230606002936 |
| Provider Name | Tina Marie Elliott |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1700418969 PECOS PAC ID: 4082072418 Enrollment ID: I20230616001857 |
| Provider Name | Kelvin Twigg |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1104083930 PECOS PAC ID: 2860841715 Enrollment ID: I20231218002041 |
| Provider Name | Dennis Allen |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1932342318 PECOS PAC ID: 0446609309 Enrollment ID: I20231218002551 |
| Provider Name | Samantha Duke |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1659049781 PECOS PAC ID: 6002268703 Enrollment ID: I20240118001449 |
| Provider Name | Jennifer Shook |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1558915728 PECOS PAC ID: 8123461316 Enrollment ID: I20240205001983 |
| Provider Name | Jenna L York |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1770915357 PECOS PAC ID: 5496198624 Enrollment ID: I20240205003063 |
| Provider Name | Sandra J Duecker |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1306990437 PECOS PAC ID: 3577906619 Enrollment ID: I20240206002747 |
| Provider Name | Alexander Allison |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1790472769 PECOS PAC ID: 0840737268 Enrollment ID: I20240802003011 |
| Provider Name | Gina Cale |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1487856688 PECOS PAC ID: 9537691886 Enrollment ID: I20241011002529 |
Cornerstone Mental Health Clinic Medicare: Not Enrolled in Medicare Practice Location: 505 N Wabash Ave, Marion, IN 46952 Phone: 765-662-3971 | |
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