MEDICARE: MARY C. FAIRCHILD, LCSW, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149.010948	IL

General Provider Information

NPI Number	:	1629463641
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY C. FAIRCHILD, LCSW, LLC

Provider Business Mailing Address
First Line	:	2618 CERRO VISTA DR
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61107-1008
Country	:	US
Telephone Number	:	815-520-6676
Fax Number	:	866-724-9612

Provider Business Practice Location Address
First Line	:	5301 E STATE ST STE 202
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2392
Country	:	US
Telephone Number	:	815-520-6676
Fax Number	:	866-724-9612

Authorized Official
Title or Position	:	OWNER
Name	:	MARY C FAIRCHILD
Credential	:	LCSW
Telephone Number	:	815-520-6676

Provider Enumeration Date	:	04/06/2015
Last Update Date	:	04/08/2015

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