=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275798266
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHEASTERN ILLINOIS CENTER FOR PASTORAL COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2008
-----------------------------------------------------
Last Update Date | 07/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 S CHURCH ST
-----------------------------------------------------
City | CARMI
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62821-1658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-382-5548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 S CHURCH ST
-----------------------------------------------------
City | CARMI
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62821-1658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-382-5548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR/THERAPIST
-----------------------------------------------------
Name | MRS. BRENDA L. KNUCKLES
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 618-382-5548
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 180003304
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------