Provider Demographics
NPI:1609621796
Name:FISHER, SHONTAE L
Entity type:Individual
Prefix:
First Name:SHONTAE
Middle Name:L
Last Name:FISHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-5054
Mailing Address - Country:US
Mailing Address - Phone:773-220-6268
Mailing Address - Fax:
Practice Address - Street 1:313 BERKSHIRE DR
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-5054
Practice Address - Country:US
Practice Address - Phone:773-220-6268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00000000000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health