Provider Demographics
NPI:1619129525
Name:FISHER, MARYLAN L
Entity Type:Individual
Prefix:
First Name:MARYLAN
Middle Name:L
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 1:800 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3510
Mailing Address - Country:US
Mailing Address - Phone:501-364-3620
Mailing Address - Fax:501-364-3994
Practice Address - Street 1:206 BRAGG ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:AR
Practice Address - Zip Code:71671-2500
Practice Address - Country:US
Practice Address - Phone:870-226-7844
Practice Address - Fax:479-750-0937
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR717 M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker