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General NPI Number Information
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NPI Number | 1003094988
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Entity Type | Organization
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Legal Business Name | SOUTH EASTERN ILLINOIS COUNSELING CENTER INC
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Dates
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Enumeration Date | 02/04/2008
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Last Update Date | 07/23/2009
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Provider Practice Location Address
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Address Line | 118 W NORTH AVE
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City | FLORA
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State | IL
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Zip | 62839-1612
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Country | US
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Telephone | 618-662-2289
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Fax | 618-662-2906
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Provider Business Mailing Address
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Address Line | PO BOX M
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City | OLNEY
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State | IL
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Zip | 62450-0913
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Country | US
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Telephone | 618-395-4306
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Fax | 618-395-4507
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. GLENN JACKSON
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Credential | M.DIV., LSW, LCPC
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Telephone | 618-395-4309
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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