NPIMap

Organization Active NPI

Southern Illinois University Carbondale Clinical Center

  • Psychologist
  • Carbondale, IL
National Provider Identifier
1174919351
Registry record updated Apr 14, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
PsychologistTaxonomy code 103T00000X
Legal business name
SOUTHERN ILLINOIS UNIVERSITY CARBONDALE CLINICAL CENTER
Practice address
625 Wham Drive Room 141
Carbondale, IL 62901
Phone
(618) 453-2361
Fax
(618) 453-6130
NPI assigned
Apr 14, 2015
Organization subpart
Yes
Parent organization
SOUTHERN ILLINOIS UNIVERSITY CARBONDALEAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 14, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Holly Cormier, PHD
Title
Director
Phone
(618) 453-2361

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103T00000X Primary
Counseling PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC1900X
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X
Speech-Language PathologistGroup: 193200000X MULTI-SPECIALTY GROUP 235Z00000X

Addresses

Primary practice location

625 Wham Drive Room 141
Carbondale, IL 62901

Mailing address

625 Wham Drive Room 141
Carbondale, IL 62901
Phone (618) 453-2361

National Provider Directory

National Provider Directory
Tax ID family
Southern Il University29 organizations share this tax ID, including this one
Part of
Southern Il University

Other organizations with this tax ID 28

Organizations that report the same tax identification number in the National Provider Directory.

View all 28

Locations

625 Wham Dr
Rm 141
Carbondale, IL 62901
Phone (618) 453-2361

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1428969600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1428969600000",
    "number": "1174919351",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "625 WHAM DRIVE ROOM 141",
            "city": "CARBONDALE",
            "state": "IL",
            "postal_code": "62901",
            "telephone_number": "618-453-2361",
            "fax_number": "618-453-6130"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "625 WHAM DRIVE ROOM 141",
            "city": "CARBONDALE",
            "state": "IL",
            "postal_code": "62901",
            "telephone_number": "618-453-2361",
            "fax_number": "618-453-6130"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN ILLINOIS UNIVERSITY CARBONDALE CLINICAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTHERN ILLINOIS UNIVERSITY CARBONDALE",
        "enumeration_date": "2015-04-14",
        "last_updated": "2015-04-14",
        "status": "A",
        "authorized_official_last_name": "CORMIER",
        "authorized_official_first_name": "HOLLY",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "618-453-2361",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "103TC1900X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Counseling",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "235Z00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Speech-Language Pathologist",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Carbondale, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 14, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.