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General NPI Number Information
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NPI Number | 1447055462
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Entity Type | Individual
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Provider Name | FABIAN BRICE CHURCHILL LSW
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Gender | Male
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Dates
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Enumeration Date | 02/14/2025
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Last Update Date | 02/14/2025
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Provider Practice Location Address
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Address Line | 6360 OLD HIGHWAY 13
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City | CARBONDALE
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State | IL
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Zip | 62901-5449
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Country | US
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Telephone | 815-557-1433
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Fax | 618-997-7972
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Provider Business Mailing Address
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Address Line | 11264 IL-37
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City | MARION, IL
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State | IL
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Zip | 62959
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Country | US
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Telephone | 618-997-2129
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 150.113927
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License Number State | IL
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