Provider Demographics
NPI:1013559517
Name:FISHBACK, KRISTEN ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ANN
Last Name:FISHBACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 KELLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-3811
Mailing Address - Country:US
Mailing Address - Phone:573-582-1234
Mailing Address - Fax:573-582-1212
Practice Address - Street 1:340 KELLEY PKWY
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-3811
Practice Address - Country:US
Practice Address - Phone:573-582-1234
Practice Address - Fax:573-582-1212
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150158001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical