Healthcare Provider Details

I. General information

NPI: 1649708926
Provider Name (Legal Business Name): SUSAN KAY SELOCK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 S 14TH ST STE 1
HERRIN IL
62948-3673
US

IV. Provider business mailing address

PO BOX 3988
CARBONDALE IL
62902-3988
US

V. Phone/Fax

Practice location:
  • Phone: 618-988-6171
  • Fax: 618-351-6491
Mailing address:
  • Phone: 618-457-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149012440
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: