MEDICARE: MONA D. FISHBANE PH.D.

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	103TC0700X	Clinical Psychologist	071004171	IL

General Provider Information

NPI Number	:	1073720637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONA D. FISHBANE PH.D.

Provider Business Mailing Address
First Line	:	1803 SAINT JOHNS AVE
Second Line	:
City	:	HIGHLAND PARK
State	:	IL
Zip	:	60035-3298
Country	:	US
Telephone Number	:	847-432-2096
Fax Number	:

Provider Business Practice Location Address
First Line	:	1803 SAINT JOHNS AVE
Second Line	:
City	:	HIGHLAND PARK
State	:	IL
Zip	:	60035-3298
Country	:	US
Telephone Number	:	847-432-2096
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	04/25/2013

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