| Organization Name: | SOUTHERN IL INSTITUTE OF BEHAVIORAL HEALTH PC |
| NPI Number: | 1346562881 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TRACY LYNN SASHIDHARAN (TREASURER) |
| Mailing Address: | 9 Junction Dr W Suite 6 Glen Carbon |
| State: | IL US |
| Postal Code: | 620342931 |
| Phone Number: | 6187104123 |
| Fax Number: | 6187314082 |
| NPI Enumeration Date: | 02/25/2010 |
| NPI Last Update Date: | 05/19/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | 018.0007365 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | IL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |