Provider Demographics
NPI:1881182434
Name:FISHER, NATHANIEL (LICDC, LPC)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:LICDC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 CLOVERDALE RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-3111
Mailing Address - Country:US
Mailing Address - Phone:419-870-2104
Mailing Address - Fax:
Practice Address - Street 1:5726 SOUTHWYCK BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-1559
Practice Address - Country:US
Practice Address - Phone:419-865-5690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161551103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1487088209Medicaid