Provider Demographics
NPI:1700600673
Name:FISH, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:FISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:
Other - Last Name:FISH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2720 CALIFORNIA RD
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2720 CALIFORNIA RD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1220
Practice Address - Country:US
Practice Address - Phone:574-262-5861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1365089103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool