Healthcare Provider Details

I. General information

NPI: 1801103528
Provider Name (Legal Business Name): ERIN MARLENE FABISH M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 E EMPIRE ST
BLOOMINGTON IL
61704-3630
US

IV. Provider business mailing address

1923 MARINA DR
NORMAL IL
61761-9356
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-7872
  • Fax:
Mailing address:
  • Phone: 815-228-4997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146.009297
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: