Provider Demographics
NPI:1457658189
Name:LIBERTY COUNSELING CENTER, INC
Entity Type:Organization
Organization Name:LIBERTY COUNSELING CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:EYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS,CADC,MISAII
Authorized Official - Phone:217-479-0691
Mailing Address - Street 1:1429 S MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-3476
Mailing Address - Country:US
Mailing Address - Phone:217-479-0691
Mailing Address - Fax:217-478-2060
Practice Address - Street 1:1429 S MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3476
Practice Address - Country:US
Practice Address - Phone:217-479-0691
Practice Address - Fax:217-478-2060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-7302-0001-A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC/A-7302-0001-AMedicaid