1275798266 NPI number — SOUTHEASTERN ILLINOIS CENTER FOR PASTORAL COUNSELING

Table of content: DR. JANEEN LOUISE WALLACE D.C. (NPI 1487651147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275798266 NPI number — SOUTHEASTERN ILLINOIS CENTER FOR PASTORAL COUNSELING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN ILLINOIS CENTER FOR PASTORAL COUNSELING
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275798266
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 S CHURCH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARMI
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62821-1658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-382-5548
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 S CHURCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARMI
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62821-1658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-382-5548
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KNUCKLES
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
COUNSELOR/THERAPIST
Authorized Official Telephone Number:
618-382-5548

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  180003304 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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