Provider Demographics
NPI:1770690539
Name:FISHER, MICAELA KIM (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:KIM
Last Name:FISHER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MRS
Other - First Name:MICAELA
Other - Middle Name:M
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:211 W CHICAGO AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3357
Mailing Address - Country:US
Mailing Address - Phone:630-455-4000
Mailing Address - Fax:630-455-4400
Practice Address - Street 1:211 W CHICAGO AVE STE 112
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3357
Practice Address - Country:US
Practice Address - Phone:630-455-4000
Practice Address - Fax:630-455-4400
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146007005235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146007005OtherIDPR LICENSE #
IL02232323OtherBCBS ILLINOIS PROVIDER #