Provider Demographics
NPI:1356717151
Name:CHURCHWELL PSYCHIATRY, S.C.
Entity type:Organization
Organization Name:CHURCHWELL PSYCHIATRY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CHURCHWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-239-3951
Mailing Address - Street 1:636 CHURCH ST STE 409A
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4580
Mailing Address - Country:US
Mailing Address - Phone:312-239-3951
Mailing Address - Fax:888-835-4696
Practice Address - Street 1:636 CHURCH ST STE 409A
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4580
Practice Address - Country:US
Practice Address - Phone:312-239-3951
Practice Address - Fax:888-835-4696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-15
Last Update Date:2015-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042620450261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health