Provider Demographics
NPI:1174919351
Name:SOUTHERN ILLINOIS UNIVERSITY CARBONDALE CLINICAL CENTER
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS UNIVERSITY CARBONDALE CLINICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CORMIER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:618-453-2361
Mailing Address - Street 1:625 WHAM DRIVE ROOM 141
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901
Mailing Address - Country:US
Mailing Address - Phone:618-453-2361
Mailing Address - Fax:618-453-6130
Practice Address - Street 1:625 WHAM DRIVE ROOM 141
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-453-2361
Practice Address - Fax:618-453-6130
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN ILLINOIS UNIVERSITY CARBONDALE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty