Healthcare Provider Details

I. General information

NPI: 1720775893
Provider Name (Legal Business Name): CARBONDALE DUI & COUNSELING ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 S COURT ST
MARION IL
62959-2816
US

IV. Provider business mailing address

502 S COURT ST
MARION IL
62959-2816
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-3013
  • Fax: 618-998-8018
Mailing address:
  • Phone: 618-993-3013
  • Fax: 618-998-8018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. CORTNEY M GRASSL
Title or Position: PROGRAM DIRECTOR
Credential: LCSW, CADC
Phone: 618-993-3013