Provider Demographics
NPI:1215206982
Name:FISAK, ERIC M (MT-BC)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:M
Last Name:FISAK
Suffix:
Gender:M
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 E KING ST
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-1615
Mailing Address - Country:US
Mailing Address - Phone:717-658-0180
Mailing Address - Fax:
Practice Address - Street 1:131 E MCKINLEY ST
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-3522
Practice Address - Country:US
Practice Address - Phone:717-267-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA10083225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist