Provider Demographics
NPI:1962737379
Name:FISKE, GWENDOLYN MASON (PHD)
Entity type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:MASON
Last Name:FISKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 OLD ORCHARD RD STE 17
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1027
Mailing Address - Country:US
Mailing Address - Phone:847-983-0107
Mailing Address - Fax:
Practice Address - Street 1:1047 DARROW AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202
Practice Address - Country:US
Practice Address - Phone:847-271-6840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-03
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist