Provider Demographics
NPI:1790954170
Name:FISKE, LIBERTY (LSW)
Entity Type:Individual
Prefix:
First Name:LIBERTY
Middle Name:
Last Name:FISKE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 ATLANTIC PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-842-6556
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:12 UNION ST
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2739
Practice Address - Country:US
Practice Address - Phone:207-701-4477
Practice Address - Fax:207-701-4486
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELS8349104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker