MEDICARE: FISH FAMILY AND ASSOCIATES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW9428	FL

General Provider Information

NPI Number	:	1689969792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FISH FAMILY AND ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	1642 N VOLUSIA AVE
Second Line	:	SUITE 203
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-3842
Country	:	US
Telephone Number	:	386-456-0008
Fax Number	:

Provider Business Practice Location Address
First Line	:	1642 N VOLUSIA AVE
Second Line	:	SUITE 203
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-3842
Country	:	US
Telephone Number	:	386-456-0008
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	MR. LOREN H. FISH II
Credential	:	LCSW
Telephone Number	:	386-456-0008

Provider Enumeration Date	:	06/16/2011
Last Update Date	:	06/16/2011

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