Provider Demographics
NPI:1659985810
Name:CHADWICK-FISHER, KEVIN ANDREW (SSP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANDREW
Last Name:CHADWICK-FISHER
Suffix:
Gender:M
Credentials:SSP
Other - Prefix:
Other - First Name:KEVIN
Other - Middle Name:ANDREW
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SSP
Mailing Address - Street 1:2411 PATHWAYS XING
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-5885
Mailing Address - Country:US
Mailing Address - Phone:618-355-4724
Mailing Address - Fax:
Practice Address - Street 1:2411 PATHWAYS XING
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-5885
Practice Address - Country:US
Practice Address - Phone:618-355-4724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2453617103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool