Provider Demographics
NPI:1235104084
Name:FISHER, BRUCE R (MSW LICSW)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:R
Last Name:FISHER
Suffix:
Gender:M
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3310 NICOLLET AVE
Mailing Address - Street 2:#406
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4495
Mailing Address - Country:US
Mailing Address - Phone:612-309-5965
Mailing Address - Fax:651-647-1861
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 435 S.
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:651-647-1900
Practice Address - Fax:651-647-1861
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN16341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN968557000Medicaid
MN800001786Medicare ID - Type Unspecified
MN968557000Medicaid