Healthcare Provider Details

I. General information

NPI: 1285185173
Provider Name (Legal Business Name): SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 S. LEWIS LANE
CARBONDALE IL
62901
US

IV. Provider business mailing address

PO BOX 577 109 CALIFORNIA ST.
CARTERVILLE IL
62918-0577
US

V. Phone/Fax

Practice location:
  • Phone: 618-519-9200
  • Fax: 618-549-1288
Mailing address:
  • Phone: 618-985-8221
  • Fax: 618-985-6860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH80CS00667
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberH80CS00667
License Number StateIL

VIII. Authorized Official

Name: CHRISTINA CARNEY
Title or Position: CEO
Credential:
Phone: 618-956-9521