Individual
SHELIA TYRELL CISCO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
904 E. MARTIN LUTHER KING, CENTRALIA, IL 62801-3058
(618) 533-1391
Mailing address
904 E. MARTIN LUTHER KING, CENTRALIA, IL 62801-3058
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
101YP2500X
Professional Counselor
180.017063
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
180.017063
STATE LICENSE
IL
05
—
370915481007
—
IL
Enumeration date
08/11/2016
Last updated
05/12/2025
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