| Organization Name: | COMMUNITY LIFE CONCEPTS OF SOUTHERN ILLINOIS, NPC |
| NPI Number: | 1336292135 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | PHILIP C NORDSTROM (REGISTERED AGENT) |
| Mailing Address: | 473 W Harrison Rd Murphysboro |
| State: | IL US |
| Postal Code: | 629664782 |
| Phone Number: | 6188672222 |
| Fax Number: | 6186873102 |
| NPI Enumeration Date: | 01/18/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 149-0100100 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |