=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700640794
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TEENAJOE FISCHER LMSW, LGSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2024
-----------------------------------------------------
Last Update Date | 12/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2405 8TH ST SOUTH SUITE 200
-----------------------------------------------------
City | MOORHEAD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-331-4866
-----------------------------------------------------
Fax | 218-331-4867
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2837 EVERGREEN RD N
-----------------------------------------------------
City | FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6688
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 34178
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------