Provider Demographics
NPI:1891435657
Name:SOUTHERN ILLINOIS THERAPY SERVICES, PLLC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS THERAPY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LCSW
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KIMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:618-218-4544
Mailing Address - Street 1:205 BAILEY LN STE 3W
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-1921
Mailing Address - Country:US
Mailing Address - Phone:618-218-4544
Mailing Address - Fax:
Practice Address - Street 1:205 BAILEY LN STE 3W
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-1921
Practice Address - Country:US
Practice Address - Phone:618-218-4544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-30
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)