Provider Demographics
NPI:1093869133
Name:FISH, KIM MAXWELL (LCSW, LMHC)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MAXWELL
Last Name:FISH
Suffix:
Gender:F
Credentials:LCSW, LMHC
Other - Prefix:MRS
Other - First Name:KIM
Other - Middle Name:S
Other - Last Name:FISH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW, LISW
Mailing Address - Street 1:4903 COVENTRY PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7133
Mailing Address - Country:US
Mailing Address - Phone:419-559-6370
Mailing Address - Fax:260-407-0094
Practice Address - Street 1:3948 NEW VISION DR STE D
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1721
Practice Address - Country:US
Practice Address - Phone:260-407-7285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 08003711041C0700X
IN39000977A101YM0800X
IN34004143A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health