Provider Demographics
NPI:1144319237
Name:FISHACK, STEPHEN R (MSW)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:R
Last Name:FISHACK
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 373
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-0373
Mailing Address - Country:US
Mailing Address - Phone:912-678-3098
Mailing Address - Fax:912-764-5661
Practice Address - Street 1:106 OAK ST STE A
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0988
Practice Address - Country:US
Practice Address - Phone:912-678-3098
Practice Address - Fax:912-764-5661
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBDMB01Medicare ID - Type Unspecified