Provider Demographics
NPI:1699180034
Name:FEHRENBACHER, MARYPAT (HIS)
Entity Type:Individual
Prefix:
First Name:MARYPAT
Middle Name:
Last Name:FEHRENBACHER
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 N WATER ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4269
Mailing Address - Country:US
Mailing Address - Phone:217-875-5555
Mailing Address - Fax:217-875-9640
Practice Address - Street 1:2890 S MOUNT ZION RD
Practice Address - Street 2:SUITE A
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-9721
Practice Address - Country:US
Practice Address - Phone:217-864-4327
Practice Address - Fax:217-864-0878
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3130237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist