Provider Demographics
NPI:1821207309
Name:SOUTHWEST FAMILY & CHILDRENS TESTING & THERAPY CLINIC
Entity Type:Organization
Organization Name:SOUTHWEST FAMILY & CHILDRENS TESTING & THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:L
Authorized Official - Last Name:ECKERT
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:618-632-7400
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:501 EMILY DRIVE
Mailing Address - City:OFALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269
Mailing Address - Country:US
Mailing Address - Phone:618-632-7400
Mailing Address - Fax:618-632-8376
Practice Address - Street 1:501 EMILY DRIVE
Practice Address - Street 2:
Practice Address - City:OFALLON
Practice Address - State:IL
Practice Address - Zip Code:62269
Practice Address - Country:US
Practice Address - Phone:618-632-7400
Practice Address - Fax:618-632-8376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty