Provider Demographics
NPI:1912382508
Name:FISH, MONICA DANIELLE
Entity Type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:DANIELLE
Last Name:FISH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MONICA
Other - Middle Name:DANIELLE
Other - Last Name:JEFFERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4347 SW GARDEN HOME RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-3584
Mailing Address - Country:US
Mailing Address - Phone:503-866-9676
Mailing Address - Fax:
Practice Address - Street 1:4347 SW GARDEN HOME RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-3584
Practice Address - Country:US
Practice Address - Phone:503-866-9676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health