Provider Demographics
NPI:1376819334
Name:FISH, ROBERTA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:MARIE
Last Name:FISH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:696 TORCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-9462
Mailing Address - Country:US
Mailing Address - Phone:407-719-4490
Mailing Address - Fax:
Practice Address - Street 1:1642 N VOLUSIA AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-3842
Practice Address - Country:US
Practice Address - Phone:386-456-0008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW64481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical