Basic Information
| Provider Information | |||||||||
| NPI: | 1316323439 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | THERESA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39029 GARDENSIDE DR | ||||||||
| Address2: | |||||||||
| City: | WILLOUGHBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440947909 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 39029 GARDENSIDE DR | ||||||||
| Address2: | |||||||||
| City: | WILLOUGHBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440947909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003307711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2015 | ||||||||
| LastUpdateDate: | 07/31/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 0119006696 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.