Provider Demographics
NPI:1760847420
Name:FISH, ANTONIO (PP)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:FISH
Suffix:
Gender:M
Credentials:PP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1449 RAINTREE DR APT J
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2717
Mailing Address - Country:US
Mailing Address - Phone:678-748-0010
Mailing Address - Fax:
Practice Address - Street 1:5680 FULTON INDUSTRIAL BLVD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30336-2659
Practice Address - Country:US
Practice Address - Phone:404-346-3471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor