Organization
COMMUNITY LIFE CONCEPTS OF SOUTHERN ILLINOIS, NPC
Active
Other names
Community Life Counseling Center
Organization subpart
No
Provider details
NPI number
Authorized official
DR. PHILIP C NORDSTROM PHD (REGISTERED AGENT)
(618) 867-2222
Entity
Organization
Contact information
Practice address
473 W HARRISON RD, MURPHYSBORO, IL 62966-4782
(618) 867-2222
(618) 687-3102
Mailing address
473 W HARRISON RD, MURPHYSBORO, IL 62966-4782
(618) 867-2222
(618) 687-3102
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
149-0100100
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
03932042
BLUE CROSS BLUE SHIELD IL
IL
01
—
122970
HEALTHALLIANCE
IL
Enumeration date
01/18/2007
Last updated
08/22/2020
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