Provider Demographics
NPI:1598007148
Name:FISH, TINAMARIE (LMHC, MHP, CCTP)
Entity Type:Individual
Prefix:MS
First Name:TINAMARIE
Middle Name:
Last Name:FISH
Suffix:
Gender:F
Credentials:LMHC, MHP, CCTP
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:MIVSHEK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 826
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-0826
Mailing Address - Country:US
Mailing Address - Phone:360-773-8964
Mailing Address - Fax:
Practice Address - Street 1:2512 E EVERGREEN BLVD # 1188
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-4323
Practice Address - Country:US
Practice Address - Phone:360-773-8964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-21
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC7332101YM0800X, 101YP2500X
WAMC 60190151101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional