Provider Demographics
NPI:1346704301
Name:FISHBACK PSYCHOLOGICAL SERVICES, P.C.
Entity Type:Organization
Organization Name:FISHBACK PSYCHOLOGICAL SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHBACK
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:704-467-6603
Mailing Address - Street 1:PO BOX 1034
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28082-1034
Mailing Address - Country:US
Mailing Address - Phone:704-467-6603
Mailing Address - Fax:704-918-1824
Practice Address - Street 1:236 LEPHILLIP COURT
Practice Address - Street 2:SUITE D
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025
Practice Address - Country:US
Practice Address - Phone:704-467-6603
Practice Address - Fax:704-918-1824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107084Medicaid