Provider Demographics
NPI:1013495456
Name:FISHER, CHANELL N
Entity Type:Individual
Prefix:
First Name:CHANELL
Middle Name:N
Last Name:FISHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHANELL
Other - Middle Name:N
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:621 REVEILLE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-3933
Mailing Address - Country:US
Mailing Address - Phone:817-713-1607
Mailing Address - Fax:
Practice Address - Street 1:1221 ABRAMS RD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-5578
Practice Address - Country:US
Practice Address - Phone:972-638-7199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-28
Last Update Date:2018-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX76377101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional