Provider Demographics
NPI:1336292135
Name:COMMUNITY LIFE CONCEPTS OF SOUTHERN ILLINOIS, NPC
Entity Type:Organization
Organization Name:COMMUNITY LIFE CONCEPTS OF SOUTHERN ILLINOIS, NPC
Other - Org Name:COMMUNITY LIFE COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:C
Authorized Official - Last Name:NORDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:618-867-2222
Mailing Address - Street 1:473 W HARRISON RD
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-4782
Mailing Address - Country:US
Mailing Address - Phone:618-867-2222
Mailing Address - Fax:618-687-3102
Practice Address - Street 1:473 W HARRISON RD
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-4782
Practice Address - Country:US
Practice Address - Phone:618-867-2222
Practice Address - Fax:618-687-3102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-01001001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03932042OtherBLUE CROSS BLUE SHIELD IL
IL122970OtherHEALTHALLIANCE
IL03932042OtherBLUE CROSS BLUE SHIELD IL