Provider Demographics
NPI:1356009773
Name:DORMANS, CYNTHIA
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:DORMANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-0639
Mailing Address - Country:US
Mailing Address - Phone:618-288-8085
Mailing Address - Fax:618-288-8959
Practice Address - Street 1:101 E EDWARDSVILLE RD
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1369
Practice Address - Country:US
Practice Address - Phone:618-296-5390
Practice Address - Fax:618-288-8959
Is Sole Proprietor?:No
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4A00-IPI-032Medicaid