Provider Demographics
NPI:1962021527
Name:FISHER, IVY LOREN
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:LOREN
Last Name:FISHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 CENTER BLVD APT 206
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11109-5633
Mailing Address - Country:US
Mailing Address - Phone:914-584-7507
Mailing Address - Fax:
Practice Address - Street 1:1000 10TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1147
Practice Address - Country:US
Practice Address - Phone:914-584-7507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health