Healthcare Provider Details

I. General information

NPI: 1700860053
Provider Name (Legal Business Name): TAMMY LYNNE FISH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NASH STREET BUILDING # T-28 DEPARTMENT OF BEHAVIORAL HEALTH
FORT DRUM NY
13602
US

IV. Provider business mailing address

410 HOLCOMB ST
WATERTOWN NY
13601-3907
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-0961
  • Fax:
Mailing address:
  • Phone: 315-681-6522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC002400
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: