Provider Demographics
NPI:1720474794
Name:FABRY, DOUGLAS SKIP (LPTA)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:SKIP
Last Name:FABRY
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 W AGARD ST
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:IL
Mailing Address - Zip Code:61491-1324
Mailing Address - Country:US
Mailing Address - Phone:309-883-5733
Mailing Address - Fax:
Practice Address - Street 1:202 W AGARD ST
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:IL
Practice Address - Zip Code:61491-1324
Practice Address - Country:US
Practice Address - Phone:309-883-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.003513225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant