Provider Demographics
NPI:1518411131
Name:CISCO, SHELIA TYRELL
Entity type:Individual
Prefix:
First Name:SHELIA
Middle Name:TYRELL
Last Name:CISCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 E. MARTIN LUTHER KING
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3058
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:904 E. MARTIN LUTHER KING
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3058
Practice Address - Country:US
Practice Address - Phone:618-533-1391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.017063101YP2500X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370915481007Medicaid
IL180.017063OtherSTATE LICENSE