Organization
CHILD AND ADOLESCENT NEUROPSYCHOLOGY SERVICES OF SOUTHERN ILLINOIS, PL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHELLE YVONNE KIBBY-FAGLIER PHD (CLINICAL NEUROPSYCHOLOGIST)
(618) 201-8828
Entity
Organization
Contact information
Practice address
285 LAKE INDIAN HILLS DR, CARBONDALE, IL 62902-6184
(618) 490-1263
Mailing address
285 LAKE INDIAN HILLS DR, CARBONDALE, IL 62902-6184
(618) 490-1263
Taxonomy
Speciality
Code
Description
License number
State
261QD1600X
Developmental Disabilities Clinic/Center
—
—
261QM0855X
Adolescent and Children Mental Health Clinic/Center
Primary
—
—
Other
Enumeration date
01/17/2020
Last updated
01/17/2020
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