Provider Demographics
NPI:1083851182
Name:SOUTHERN IL REGIONAL SOCIAL SERVICES
Entity Type:Organization
Organization Name:SOUTHERN IL REGIONAL SOCIAL SERVICES
Other - Org Name:SOUTHERN ILLINOIS REGIONAL SOCIAL SERVICES, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:S
Authorized Official - Last Name:FREITAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-457-6703
Mailing Address - Street 1:604 E COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3309
Mailing Address - Country:US
Mailing Address - Phone:618-457-6703
Mailing Address - Fax:618-457-8377
Practice Address - Street 1:602 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3309
Practice Address - Country:US
Practice Address - Phone:618-457-6703
Practice Address - Fax:618-457-8377
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN IL REGIONAL SOCIAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-12
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0243-0001-A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========007Medicaid