Provider Demographics
NPI:1679589220
Name:SOUTH SIDE CHRISTIAN COUNSELING CENTER GROUP
Entity Type:Organization
Organization Name:SOUTH SIDE CHRISTIAN COUNSELING CENTER GROUP
Other - Org Name:SOUTHSIDE CHRISTIAN COUNSELING CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:HAUSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-887-0399
Mailing Address - Street 1:408 MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:LOHRVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:51453
Mailing Address - Country:US
Mailing Address - Phone:712-887-0399
Mailing Address - Fax:708-633-1823
Practice Address - Street 1:16537 OAK PARK AVE.
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477
Practice Address - Country:US
Practice Address - Phone:708-633-9003
Practice Address - Fax:708-633-1823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-003931106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1618179OtherBLUE CROSS BLUE SHIELD
IL7092108OtherAETNA INSURANCE