Provider Demographics
NPI:1699388009
Name:MACKICHAN, IAN (MSW LCSW CADC)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:MACKICHAN
Suffix:
Gender:M
Credentials:MSW LCSW CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-3108
Mailing Address - Country:US
Mailing Address - Phone:217-377-2211
Mailing Address - Fax:
Practice Address - Street 1:507 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-3108
Practice Address - Country:US
Practice Address - Phone:217-377-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0224581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical