Healthcare Provider Details

I. General information

NPI: 1366952079
Provider Name (Legal Business Name): NATALIE LANAE FISH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2017
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5870 ARLINGTON AVE # 103
RIVERSIDE CA
92504-2037
US

IV. Provider business mailing address

10531 POLAND PL
BANNING CA
92220-1561
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-6596
  • Fax:
Mailing address:
  • Phone: 951-206-1173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number8753-R
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number198753
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: