Provider Demographics
NPI:1184403057
Name:ST. CLAIR, EMILIE
Entity type:Individual
Prefix:
First Name:EMILIE
Middle Name:
Last Name:ST. CLAIR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 ROGER AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-1772
Mailing Address - Country:US
Mailing Address - Phone:224-406-5981
Mailing Address - Fax:
Practice Address - Street 1:522 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-2240
Practice Address - Country:US
Practice Address - Phone:618-566-0313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
ILRBT-24-336897106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician