Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 180-007284 | IL |
NPI | 1003131541 |
---|---|
Provider Name | Ms. Debra Fay Disney |
First Address | Peoria, IL 61614-1588 |
Second Address | Peoria, IL 61614-1588 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2010 |
Last Update Date | 20/05/2011 |