Provider Demographics
NPI:1366686735
Name:FISHER, LAVERN M (MA)
Entity Type:Individual
Prefix:MRS
First Name:LAVERN
Middle Name:M
Last Name:FISHER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1400
Mailing Address - Street 2:
Mailing Address - City:KALAMA
Mailing Address - State:WA
Mailing Address - Zip Code:98625-1200
Mailing Address - Country:US
Mailing Address - Phone:360-431-9987
Mailing Address - Fax:
Practice Address - Street 1:803 VANDERCOOK WAY STE 9
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4039
Practice Address - Country:US
Practice Address - Phone:360-431-9987
Practice Address - Fax:360-539-0010
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00043956101YM0800X
WALH60110623101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health