Provider Demographics
NPI:1447055462
Name:CHURCHILL, FABIAN BRICE (LSW)
Entity type:Individual
Prefix:
First Name:FABIAN
Middle Name:BRICE
Last Name:CHURCHILL
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11264 IL-37
Mailing Address - Street 2:
Mailing Address - City:MARION, IL
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-997-2129
Mailing Address - Fax:
Practice Address - Street 1:6360 OLD HIGHWAY 13
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5449
Practice Address - Country:US
Practice Address - Phone:815-557-1433
Practice Address - Fax:618-997-7972
Is Sole Proprietor?:No
Enumeration Date:2025-02-14
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.113927101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health