Provider Demographics
NPI:1225510282
Name:FISHER, GERARD KIMBLE
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:KIMBLE
Last Name:FISHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GERARD
Other - Middle Name:EDWARD
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E OAKLAND PARK BLVD # 126
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-2148
Mailing Address - Country:US
Mailing Address - Phone:410-949-7888
Mailing Address - Fax:
Practice Address - Street 1:1951 NW 34TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33309-5744
Practice Address - Country:US
Practice Address - Phone:410-949-7888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA121072101YM0800X
FLSW15637101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health