Provider Demographics
NPI:1003538950
Name:FASKEN, WALTER
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:FASKEN
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 1:7648 S OCONTO AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60455-1323
Mailing Address - Country:US
Mailing Address - Phone:708-979-1815
Mailing Address - Fax:
Practice Address - Street 1:111 BUCKLIN ST STE 1
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-2382
Practice Address - Country:US
Practice Address - Phone:815-780-0690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36350101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)