Provider Demographics
NPI:1689568313
Name:FISHER, DE'ERIC
Entity type:Individual
Prefix:
First Name:DE'ERIC
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 N DEARBORN ST APT 1218
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-5045
Mailing Address - Country:US
Mailing Address - Phone:773-780-4653
Mailing Address - Fax:
Practice Address - Street 1:1163 N STATE ST LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-2722
Practice Address - Country:US
Practice Address - Phone:773-780-4653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-06
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.024241225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist