Provider Demographics
NPI:1043614530
Name:FISH, DAVID JAMES (LMSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JAMES
Last Name:FISH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30524 MCGRATH DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-5611
Mailing Address - Country:US
Mailing Address - Phone:586-484-5290
Mailing Address - Fax:
Practice Address - Street 1:27941 HARPER AVE STE 102
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1535
Practice Address - Country:US
Practice Address - Phone:586-484-5290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010712971041C0700X
MI63010712971041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool