Provider Demographics
NPI:1821263401
Name:FISCHER, MARK THOMAS (LADC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:THOMAS
Last Name:FISCHER
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-1819
Mailing Address - Country:US
Mailing Address - Phone:763-308-0006
Mailing Address - Fax:763-631-0339
Practice Address - Street 1:808 7TH AVE N APT 4
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-1241
Practice Address - Country:US
Practice Address - Phone:320-760-2264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302700101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)