Provider Demographics
NPI:1528461514
Name:BERHE, FITHAWIT
Entity type:Individual
Prefix:
First Name:FITHAWIT
Middle Name:
Last Name:BERHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5N673 SANTA FE TRL
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2413
Mailing Address - Country:US
Mailing Address - Phone:630-924-1579
Mailing Address - Fax:
Practice Address - Street 1:5N673 SANTA FE TRL
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2413
Practice Address - Country:US
Practice Address - Phone:630-924-1579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-6006553103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6692OtherHUMANA HEALTH PLAN INC MMP
IL13186OtherAETNA BETTER HEALTH
IL16628Medicaid
IL8177Medicaid
IL9857Medicaid
IL0695Medicaid
6321OtherILLINICARE