Provider Demographics
NPI:1285221796
Name:FISH, ALICIA (ATC)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:FISH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 DUNMORE CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-2615
Mailing Address - Country:US
Mailing Address - Phone:919-744-1861
Mailing Address - Fax:
Practice Address - Street 1:2428 DUNMORE CT
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-2615
Practice Address - Country:US
Practice Address - Phone:919-744-1861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00980405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional