Basic Information
| Provider Information | |||||||||
| NPI: | 1326238148 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN IL REGIONAL SOCIAL SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | SOUTHERN ILLINOIS REGIONAL SOCIAL SERVICES, INC. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 604 E COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629013309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184576703 | ||||||||
| FaxNumber: | 6184578377 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 E COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629013309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184576703 | ||||||||
| FaxNumber: | 6184578377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2007 | ||||||||
| LastUpdateDate: | 01/08/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FREITAG | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6184576703 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 180006282 | IL | N | Agencies | Community/Behavioral Health | 251S00000X | A0243-0001-A | IL | Y | Agencies | Community/Behavioral Health |
No ID Information.