Provider Demographics
NPI:1578347084
Name:FISHER, KELLEY
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:FISHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 CARRIEBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:STEPHENS CITY
Mailing Address - State:VA
Mailing Address - Zip Code:22655-6000
Mailing Address - Country:US
Mailing Address - Phone:540-686-0220
Mailing Address - Fax:
Practice Address - Street 1:130 CARRIEBROOKE DR
Practice Address - Street 2:
Practice Address - City:STEPHENS CITY
Practice Address - State:VA
Practice Address - Zip Code:22655-6000
Practice Address - Country:US
Practice Address - Phone:540-686-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040155391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty