Provider Demographics
NPI:1043991961
Name:FASKEN, BRENDEN
Entity Type:Individual
Prefix:
First Name:BRENDEN
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 1:710 PEORIA ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-3351
Mailing Address - Country:US
Mailing Address - Phone:815-780-0690
Mailing Address - Fax:815-410-1937
Practice Address - Street 1:710 PEORIA ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-3351
Practice Address - Country:US
Practice Address - Phone:815-780-0690
Practice Address - Fax:815-410-1937
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)