Healthcare Provider Details

I. General information

NPI: 1235104084
Provider Name (Legal Business Name): BRUCE R FISHER MSW LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 01/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 UNIVERSITY AVE W SUITE 435 S.
SAINT PAUL MN
55114-1052
US

IV. Provider business mailing address

3310 NICOLLET AVE #406
MINNEAPOLIS MN
55408-4495
US

V. Phone/Fax

Practice location:
  • Phone: 651-647-1900
  • Fax: 651-647-1861
Mailing address:
  • Phone: 612-309-5965
  • Fax: 651-647-1861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1634
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: