Provider Demographics
NPI:1255961348
Name:CHILD AND ADOLESCENT NEUROPSYCHOLOGY SERVICES OF SOUTHERN ILLINOIS, PL
Entity type:Organization
Organization Name:CHILD AND ADOLESCENT NEUROPSYCHOLOGY SERVICES OF SOUTHERN ILLINOIS, PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL NEUROPSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:KIBBY-FAGLIER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:618-201-8828
Mailing Address - Street 1:285 LAKE INDIAN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-6184
Mailing Address - Country:US
Mailing Address - Phone:618-490-1263
Mailing Address - Fax:
Practice Address - Street 1:285 LAKE INDIAN HILLS DR
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902-6184
Practice Address - Country:US
Practice Address - Phone:618-490-1263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities