1346704301 NPI number — FISHBACK PSYCHOLOGICAL SERVICES, P.C.

Table of content: (NPI 1346704301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346704301 NPI number — FISHBACK PSYCHOLOGICAL SERVICES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FISHBACK PSYCHOLOGICAL SERVICES, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346704301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1034
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANNAPOLIS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28082-1034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-467-6603
Provider Business Mailing Address Fax Number:
704-918-1824

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
236 LEPHILLIP COURT
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-467-6603
Provider Business Practice Location Address Fax Number:
704-918-1824
Provider Enumeration Date:
01/24/2019

Additional Information

Authorized Official

Authorized Official Last Name:
FISHBACK
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
704-467-6603

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6107084 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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