Healthcare Provider Details

I. General information

NPI: 1912434051
Provider Name (Legal Business Name): THAD WILLIAM FISHER MA, M.DIV.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: T WILL FISHER

II. Dates (important events)

Enumeration Date: 05/19/2017
Last Update Date: 05/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6417 W IRVING PARK RD
CHICAGO IL
60634-2437
US

IV. Provider business mailing address

6417 W IRVING PARK RD
CHICAGO IL
60634-2437
US

V. Phone/Fax

Practice location:
  • Phone: 773-777-7112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code374K00000X
TaxonomyReligious Nonmedical Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: