Provider Demographics
NPI:1568818557
Name:FISH, STEPHANIE (LMFT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:FISH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3833 COON RAPIDS BLVD NW
Mailing Address - Street 2:SUITE 120
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2643
Mailing Address - Country:US
Mailing Address - Phone:763-767-3350
Mailing Address - Fax:767-767-0912
Practice Address - Street 1:3833 COON RAPIDS BLVD NW
Practice Address - Street 2:SUITE 120
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2643
Practice Address - Country:US
Practice Address - Phone:763-767-3350
Practice Address - Fax:767-767-0912
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3263106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist