Provider Demographics
NPI:1164458311
Name:FISHER, UNDINE (MA)
Entity Type:Individual
Prefix:MS
First Name:UNDINE
Middle Name:
Last Name:FISHER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:DINA
Other - Middle Name:
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:305 W WALL ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-2476
Mailing Address - Country:US
Mailing Address - Phone:816-716-4237
Mailing Address - Fax:
Practice Address - Street 1:305 W WALL ST
Practice Address - Street 2:SUITE A
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-2476
Practice Address - Country:US
Practice Address - Phone:816-716-4237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY#01583103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO23375017OtherBCBS