Healthcare Provider Details

I. General information

NPI: 1134390115
Provider Name (Legal Business Name): DIANE FISHER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 02/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 SHERMAN AVE SUITE 204
EVANSTON IL
60201-3771
US

IV. Provider business mailing address

1830 SHERMAN AVE SUITE 204
EVANSTON IL
60201-3771
US

V. Phone/Fax

Practice location:
  • Phone: 847-989-1745
  • Fax: 847-920-9276
Mailing address:
  • Phone: 847-989-1745
  • Fax: 847-920-9276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number071006707
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.006707
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: