MEDICARE: DR. DALE W FABER PHD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071009890	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2223316	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1881718948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DALE W FABER PHD.

Provider Business Mailing Address
First Line	:	1035 GROVE ST
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-4636
Country	:	US
Telephone Number	:	630-926-4873
Fax Number	:	630-852-0740

Provider Business Practice Location Address
First Line	:	1035 GROVE ST
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-4636
Country	:	US
Telephone Number	:	630-926-4873
Fax Number	:	630-852-6335

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	04/05/2019

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