Provider Demographics
NPI:1841762572
Name:FISHER, CRYSTAL SHERREE JUANITA (BA)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:SHERREE JUANITA
Last Name:FISHER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3335 LT MOSS RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7222
Mailing Address - Country:US
Mailing Address - Phone:406-549-6141
Mailing Address - Fax:
Practice Address - Street 1:1725 MT HIGHWAY 35
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-2464
Practice Address - Country:US
Practice Address - Phone:406-549-6141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPSY-BA-LIC-3626103K00000X
MTPSY-ABA-LIC-2594103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT510167061Medicaid