Provider Demographics
NPI:1710772926
Name:FISHER, EDEN
Entity type:Individual
Prefix:
First Name:EDEN
Middle Name:
Last Name:FISHER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 STATE ROAD HWY 446
Mailing Address - Street 2:APT 33A
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:451 S PARK RIDGE RD # 101
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8589
Practice Address - Country:US
Practice Address - Phone:812-747-9384
Practice Address - Fax:812-413-2416
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-24-346998106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician