Provider Demographics
NPI:1346562881
Name:SOUTHERN IL INSTITUTE OF BEHAVIORAL HEALTH PC
Entity Type:Organization
Organization Name:SOUTHERN IL INSTITUTE OF BEHAVIORAL HEALTH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SASHIDHARAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, NCC, LCPC
Authorized Official - Phone:618-710-4123
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-0098
Mailing Address - Country:US
Mailing Address - Phone:618-710-4123
Mailing Address - Fax:618-731-4082
Practice Address - Street 1:9 JUNCTION DR W
Practice Address - Street 2:SUITE 6
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-2931
Practice Address - Country:US
Practice Address - Phone:618-710-4123
Practice Address - Fax:618-731-4082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-25
Last Update Date:2012-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL018.0007365101YP2500X
IL071.007664103TC0700X
IL071.007775103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty