Provider Demographics
NPI:1053857870
Name:FISHER, GWENDOLYN (LSMW)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:
Last Name:FISHER
Suffix:
Gender:F
Credentials:LSMW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14609-4732
Mailing Address - Country:US
Mailing Address - Phone:585-482-9290
Mailing Address - Fax:585-935-7433
Practice Address - Street 1:500 WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609-4732
Practice Address - Country:US
Practice Address - Phone:585-482-9290
Practice Address - Fax:585-935-7433
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0985471041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool