Provider Demographics
NPI:1629463641
Name:MARY C. FAIRCHILD, LCSW, LLC
Entity Type:Organization
Organization Name:MARY C. FAIRCHILD, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:FAIRCHILD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:815-520-6676
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 1:5301 E STATE ST STE 202
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2392
Practice Address - Country:US
Practice Address - Phone:815-520-6676
Practice Address - Fax:866-724-9612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-06
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0109481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty