Provider Demographics
NPI:1215560560
Name:FAZENDIN, MATTHEW (LCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:FAZENDIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 WESTVIEW LN
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-2768
Mailing Address - Country:US
Mailing Address - Phone:630-885-0073
Mailing Address - Fax:
Practice Address - Street 1:1560 WALL ST STE 204
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-1146
Practice Address - Country:US
Practice Address - Phone:888-345-3561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490193801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical