Provider Demographics
NPI:1336633635
Name:FISHER, KRISTIN D (MED, LCMHC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:D
Last Name:FISHER
Suffix:
Gender:F
Credentials:MED, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 AMANDA DR
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-9398
Mailing Address - Country:US
Mailing Address - Phone:804-836-4883
Mailing Address - Fax:
Practice Address - Street 1:7401 CARMEL EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-8275
Practice Address - Country:US
Practice Address - Phone:704-752-8414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13633101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000OtherCREDENTIALING IN PROCESS