Provider Demographics
NPI:1407034382
Name:SOUTH EASTERN ILLINOIS COUNSELING CENTER INC
Entity Type:Organization
Organization Name:SOUTH EASTERN ILLINOIS COUNSELING CENTER INC
Other - Org Name:WABASH FAMILY COUNSELING CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MDIV, LSW, LCPC
Authorized Official - Phone:618-395-4309
Mailing Address - Street 1:PO BOX M
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-0913
Mailing Address - Country:US
Mailing Address - Phone:618-395-4306
Mailing Address - Fax:618-395-4507
Practice Address - Street 1:602 E 5TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-2152
Practice Address - Country:US
Practice Address - Phone:618-262-7473
Practice Address - Fax:618-262-8810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL=========011Medicaid
ILIL2222Medicare UPIN