Doctor Name: | DR. AMBER LEE FASULA |
NPI Number: | 1730364472 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | PSY.D., BCN |
License Number: | 071007844 |
Business Practice Address: | 13011 S 104th Ave Suite 200 Palos Park, IL - 604641500 |
Business Phone Number: | 7084483300 |
Business Fax Number: | 7084486972 |
Mailing Address: | 13011 S 104th Ave, Suite 200 PALOS PARK |
State: | IL |
Postal Code: | 604641500 |
Phone Number: | 7084483300 |
Fax Number: | 7084486972 |
NPI Enumeration Date: | 12/31/2007 |
NPI Last Update Date: | 07/29/2010 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | 071007844 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IL |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |