Provider Demographics
NPI:1144712787
Name:FISHER, ROSA JEANENE (LPC)
Entity type:Individual
Prefix:MRS
First Name:ROSA
Middle Name:JEANENE
Last Name:FISHER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:ROSA
Other - Middle Name:JEANENE
Other - Last Name:TUTTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 360
Mailing Address - Street 2:
Mailing Address - City:BLACKSTONE
Mailing Address - State:VA
Mailing Address - Zip Code:23824-0360
Mailing Address - Country:US
Mailing Address - Phone:434-264-3209
Mailing Address - Fax:434-264-3224
Practice Address - Street 1:116 W BROAD ST
Practice Address - Street 2:
Practice Address - City:BLACKSTONE
Practice Address - State:VA
Practice Address - Zip Code:23824-1710
Practice Address - Country:US
Practice Address - Phone:434-264-3209
Practice Address - Fax:434-264-3224
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007685101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1144712787Medicaid
VA0701007685OtherLICENSED PROFESSIONAL COUNSELOR