Provider Demographics
NPI:1598949109
Name:FASULA, ERIN (PT, MPT)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:FASULA
Suffix:
Gender:F
Credentials:PT, MPT
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:
Other - Last Name:CHURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, MPT
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:
Practice Address - Street 1:7474 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2644
Practice Address - Country:US
Practice Address - Phone:158-397-4439
Practice Address - Fax:815-397-4459
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016144225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400204500Medicare PIN
IL211585008Medicare PIN