Provider Demographics
NPI:1124153879
Name:EPILEPSY FOUNDATION OF SOUTHERN ILLINOIS
Entity type:Organization
Organization Name:EPILEPSY FOUNDATION OF SOUTHERN ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EPILEPSY SERVICES COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:STUBBLEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:618-244-6680
Mailing Address - Street 1:1100 S 42ND ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6216
Mailing Address - Country:US
Mailing Address - Phone:618-244-6680
Mailing Address - Fax:618-244-6686
Practice Address - Street 1:1100 S 42ND ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6216
Practice Address - Country:US
Practice Address - Phone:618-244-6680
Practice Address - Fax:618-244-6686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable