Basic Information
Provider Information | |||||||||
NPI: | 1134155625 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LINDSAY | ||||||||
FirstName: | SALLY | ||||||||
MiddleName: | JOHONNA | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | RR 3 BOX 581 | ||||||||
Address2: |   | ||||||||
City: | VANDALIA | ||||||||
State: | IL | ||||||||
PostalCode: | 624719358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182834176 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 904 E. MARTIN LUTHER KING DR. | ||||||||
Address2: |   | ||||||||
City: | CENTRALIA | ||||||||
State: | IL | ||||||||
PostalCode: | 628013506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185331391 | ||||||||
FaxNumber: | 6185330012 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2006 | ||||||||
LastUpdateDate: | 04/02/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149-008257 | IL | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.