Healthcare Provider Details

I. General information

NPI: 1811388838
Provider Name (Legal Business Name): PATRICIA ANN FISHMAN RN, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 COVENTRY LN
CRYSTAL LAKE IL
60014-7579
US

IV. Provider business mailing address

500 COVENTRY LN
CRYSTAL LAKE IL
60014-7579
US

V. Phone/Fax

Practice location:
  • Phone: 815-455-7100
  • Fax:
Mailing address:
  • Phone: 815-455-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166.000974
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: