Healthcare Provider Details

I. General information

NPI: 1770016669
Provider Name (Legal Business Name): LYNN EICHELBERGER FIEDLER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 04/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3806 GUN CLUB RD
NEW ATHENS IL
62264-2218
US

IV. Provider business mailing address

3806 GUN CLUB RD
NEW ATHENS IL
62264-2218
US

V. Phone/Fax

Practice location:
  • Phone: 618-791-0718
  • Fax:
Mailing address:
  • Phone: 618-791-0718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149018930
License Number StateIL

VIII. Authorized Official

Name: LYNN CHRISTINE EICHELBERGER FIEDLER
Title or Position: LCSW
Credential: LCSW
Phone: 618-791-0718