Provider Demographics
NPI:1700860053
Name:FISH, TAMMY LYNNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:LYNNE
Last Name:FISH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 HOLCOMB ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3907
Mailing Address - Country:US
Mailing Address - Phone:315-681-6522
Mailing Address - Fax:
Practice Address - Street 1:NASH STREET BUILDING # T-28
Practice Address - Street 2:DEPARTMENT OF BEHAVIORAL HEALTH
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-0961
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0024001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical