Healthcare Provider Details

I. General information

NPI: 1114631967
Provider Name (Legal Business Name): SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2023
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E BOULEVARD ST
MARION IL
62959-3306
US

IV. Provider business mailing address

109 CALIFORNIA ST PO BOX 577
CARTERVILLE IL
62918
US

V. Phone/Fax

Practice location:
  • Phone: 618-519-9200
  • Fax: 618-998-0880
Mailing address:
  • Phone: 618-519-9200
  • Fax: 618-985-6860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

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