Provider Demographics
NPI:1114376092
Name:SOUTHEASTERN IL COUNSELING CTRS INC.
Entity type:Organization
Organization Name:SOUTHEASTERN IL COUNSELING CTRS INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:A/R CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HORD
Authorized Official - Suffix:
Authorized Official - Credentials:AAS
Authorized Official - Phone:618-395-4309
Mailing Address - Street 1:504 MICAH DR
Mailing Address - Street 2:DRAWER M
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-4720
Mailing Address - Country:US
Mailing Address - Phone:618-395-4306
Mailing Address - Fax:618-395-4507
Practice Address - Street 1:204 W HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-1710
Practice Address - Country:US
Practice Address - Phone:618-546-5232
Practice Address - Fax:618-546-5657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========021Medicaid
ILIL2222Medicare PIN