Provider Demographics
NPI:1316385990
Name:THE EASE PROGRAM
Entity Type:Organization
Organization Name:THE EASE PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR / SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:S
Authorized Official - Last Name:ENDICOTT-PLOG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:618-233-3273
Mailing Address - Street 1:2900 FRANK SCOTT PKWY W STE 956
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5000
Mailing Address - Country:US
Mailing Address - Phone:618-233-3273
Mailing Address - Fax:618-234-7233
Practice Address - Street 1:2900 FRANK SCOTT PKWY W STE 956
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5000
Practice Address - Country:US
Practice Address - Phone:618-233-3273
Practice Address - Fax:618-234-7233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.008683251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health