Provider Demographics
NPI:1497025670
Name:FOMLEY, ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:FOMLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10315 DAWSONS CREEK BLVD
Mailing Address - Street 2:VISION COUNSELING AND PSYCHOLOGICAL SERVICES
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10315 DAWSONS CREEK BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1912
Practice Address - Country:US
Practice Address - Phone:260-387-6340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health