Healthcare Provider Details

I. General information

NPI: 1801441290
Provider Name (Legal Business Name): KRISTINA MARIE FISKE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2019
Last Update Date: 08/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 PLEASANT HOME RD STE G1
AUGUSTA GA
30907-0560
US

IV. Provider business mailing address

7219 HOFFMAN DR
EVANS GA
30809-0360
US

V. Phone/Fax

Practice location:
  • Phone: 706-364-4599
  • Fax: 706-364-4589
Mailing address:
  • Phone: 706-339-3522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC011030
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: