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NPI Code Detail

MEDICARE: MRS. KIM MAXWELL FISH LCSW, LMHC

MEDICARE: MRS. KIM MAXWELL FISH LCSW, LMHC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social WorkerI 0800371OH
2101YM0800XMental Health Counselor39000977AIN
31041C0700XClinical Social Worker34004143AIN

General Provider Information

NPI Number : 1093869133
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. KIM MAXWELL FISH LCSW, LMHC
Provider Business Mailing Address
First Line : 4903 COVENTRY PKWY
Second Line :
City : FORT WAYNE
State : IN
Zip : 46804-7133
Country : US
Telephone Number : 419-559-6370
Fax Number : 260-407-0094
Provider Business Practice Location Address
First Line : 3948 NEW VISION DR STE D
Second Line :
City : FORT WAYNE
State : IN
Zip : 46845-1721
Country : US
Telephone Number : 260-407-7285
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/23/2007
Last Update Date : 02/25/2011

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