Healthcare Provider Details

I. General information

NPI: 1982114112
Provider Name (Legal Business Name): MARY FAFARA SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 10/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 W WOOD ST
DECATUR IL
62522-3112
US

IV. Provider business mailing address

520 W WOOD ST
DECATUR IL
62522-3112
US

V. Phone/Fax

Practice location:
  • Phone: 217-362-3385
  • Fax:
Mailing address:
  • Phone: 217-362-3385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12132766
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: