Provider Demographics
NPI:1114681079
Name:FISHER, KELLEY ROSE
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:ROSE
Last Name:FISHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 N STATE ST APT A
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-1241
Mailing Address - Country:US
Mailing Address - Phone:517-375-4327
Mailing Address - Fax:
Practice Address - Street 1:1840 W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-9672
Practice Address - Country:US
Practice Address - Phone:989-202-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician