Basic Information
| Provider Information | |||||||||
| NPI: | 1710380746 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAHNSTROM | ||||||||
| FirstName: | BRETT | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 OGDEN AVE | ||||||||
| Address2: | STE. 203 | ||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605044273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309786218 | ||||||||
| FaxNumber: | 6309786219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2014 | ||||||||
| LastUpdateDate: | 12/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070-020068 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.