Healthcare Provider Details

I. General information

NPI: 1881425361
Provider Name (Legal Business Name): AYESHA FATIMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 POINT BLVD
ELGIN IL
60123-9215
US

IV. Provider business mailing address

2130 POINT BLVD STE 200
ELGIN IL
60123-9208
US

V. Phone/Fax

Practice location:
  • Phone: 847-783-0307
  • Fax: 847-783-0730
Mailing address:
  • Phone: 847-783-0307
  • Fax: 847-783-0730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number2024032007
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number2024032007
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number297.011185
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: