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General NPI Number Information
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NPI Number | 1174919351
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Entity Type | Organization
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Legal Business Name | SOUTHERN ILLINOIS UNIVERSITY CARBONDALE CLINICAL CENTER
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Dates
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Enumeration Date | 04/14/2015
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Last Update Date | 04/14/2015
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Provider Practice Location Address
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Address Line | 625 WHAM DRIVE ROOM 141
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City | CARBONDALE
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State | IL
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Zip | 62901
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Country | US
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Telephone | 618-453-2361
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Fax | 618-453-6130
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Provider Business Mailing Address
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Address Line | 625 WHAM DRIVE ROOM 141
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City | CARBONDALE
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State | IL
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Zip | 62901
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Country | US
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Telephone | 618-453-2361
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Fax | 618-453-6130
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Authorized Official
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Title or Position | DIRECTOR
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Name | HOLLY CORMIER
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Credential | PHD
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Telephone | 618-453-2361
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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