Provider Demographics
NPI:1003094988
Name:SOUTH EASTERN ILLINOIS COUNSELING CENTER INC
Entity Type:Organization
Organization Name:SOUTH EASTERN ILLINOIS COUNSELING CENTER INC
Other - Org Name:ARBORS WEST
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MDIV, LSW, LCPC
Authorized Official - Phone:618-395-4309
Mailing Address - Street 1:PO BOX M
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-0913
Mailing Address - Country:US
Mailing Address - Phone:618-395-4306
Mailing Address - Fax:618-395-4507
Practice Address - Street 1:118 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-1612
Practice Address - Country:US
Practice Address - Phone:618-662-2289
Practice Address - Fax:618-662-2906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========037Medicaid
IL572810Medicare PIN