Healthcare Provider Details

I. General information

NPI: 1174919351
Provider Name (Legal Business Name): SOUTHERN ILLINOIS UNIVERSITY CARBONDALE CLINICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 WHAM DRIVE ROOM 141
CARBONDALE IL
62901
US

IV. Provider business mailing address

625 WHAM DRIVE ROOM 141
CARBONDALE IL
62901
US

V. Phone/Fax

Practice location:
  • Phone: 618-453-2361
  • Fax: 618-453-6130
Mailing address:
  • Phone: 618-453-2361
  • Fax: 618-453-6130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: HOLLY CORMIER
Title or Position: DIRECTOR
Credential: PHD
Phone: 618-453-2361