=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215447610
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOS CRISIS INTERVENTION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2017
-----------------------------------------------------
Last Update Date | 05/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 TERRACE CT
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-3437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-335-2938
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4020 GREEN MOUNT CROSSING DR # 325
-----------------------------------------------------
City | SHILOH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-7287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-335-2938
-----------------------------------------------------
Fax | 618-551-4377
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SHANNON FRANCO
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 618-335-2938
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 180011222
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------