Provider Demographics
NPI:1588771265
Name:FAIRCHILD, MARY C (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2618 CERRO VISTA DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1008
Mailing Address - Country:US
Mailing Address - Phone:815-520-6676
Mailing Address - Fax:866-724-9612
Practice Address - Street 1:6072 BRYNWOOD DR STE 201
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-5829
Practice Address - Country:US
Practice Address - Phone:815-520-6676
Practice Address - Fax:866-724-9612
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0109481041C0700X
IL1490109481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
242733OtherCOMPSYCH CORP
IL10132126OtherBLUE CROSS BLUE SHIELD
242733OtherCOMPSYCH CORP