Provider Demographics
NPI:1417907825
Name:FISH, CYNTHIA LEANNE (OT)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LEANNE
Last Name:FISH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:LEANNE
Other - Last Name:DIVINCENZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:1031 E MOUNTAIN ST
Mailing Address - Street 2:BUILDING 318, SUITE 101
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7997
Mailing Address - Country:US
Mailing Address - Phone:336-996-4980
Mailing Address - Fax:336-996-3521
Practice Address - Street 1:1031 E MOUNTAIN ST
Practice Address - Street 2:BUILDING 318, SUITE 101
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7997
Practice Address - Country:US
Practice Address - Phone:336-996-4980
Practice Address - Fax:336-996-3521
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5073225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7301732Medicaid