Provider Demographics
NPI:1861790883
Name:SOUTHSIDE CHRISTIAN COUNSELING CENTER
Entity type:Organization
Organization Name:SOUTHSIDE CHRISTIAN COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOEHNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-633-9003
Mailing Address - Street 1:16547 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-1752
Mailing Address - Country:US
Mailing Address - Phone:708-633-9003
Mailing Address - Fax:708-633-1823
Practice Address - Street 1:16547 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1752
Practice Address - Country:US
Practice Address - Phone:708-633-9003
Practice Address - Fax:708-633-1823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.005263101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty