Provider Demographics
NPI:1629475603
Name:FISHBURN, RUTH
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:FISHBURN
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 1:254 N 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-3003
Mailing Address - Country:US
Mailing Address - Phone:509-954-0479
Mailing Address - Fax:503-846-0709
Practice Address - Street 1:254 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-3003
Practice Address - Country:US
Practice Address - Phone:509-954-0479
Practice Address - Fax:503-846-0709
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA2664101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health