Provider Demographics
NPI:1568151967
Name:FISHER, BRANDI ANNA-LIZA D (BCBA)
Entity Type:Individual
Prefix:
First Name:BRANDI ANNA-LIZA
Middle Name:D
Last Name:FISHER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-0858
Mailing Address - Country:US
Mailing Address - Phone:719-401-1706
Mailing Address - Fax:
Practice Address - Street 1:2003 RYLAN RD
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-4227
Practice Address - Country:US
Practice Address - Phone:719-401-1706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-23-65323103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst