Healthcare Provider Details

I. General information

NPI: 1396923272
Provider Name (Legal Business Name): SOUTH EASTERN ILLINOIS COUNSELING CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 E MAIN ST
OLNEY IL
62450-2114
US

IV. Provider business mailing address

PO BOX M
OLNEY IL
62450-0913
US

V. Phone/Fax

Practice location:
  • Phone: 618-392-3090
  • Fax: 618-392-2754
Mailing address:
  • Phone: 618-395-4306
  • Fax: 618-395-4507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: MR. GLENN JACKSON
Title or Position: EXECUTIVE DIRECTOR
Credential: M. DIV., LSW, LCPC
Phone: 618-395-4309