Provider Demographics
NPI:1205084522
Name:FISHER, THERESA M (MACCC/SLP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:FISHER
Suffix:
Gender:F
Credentials:MACCC/SLP
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:M
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MACCC/SLP
Mailing Address - Street 1:1790 SANSDAN CT
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-4738
Mailing Address - Country:US
Mailing Address - Phone:440-354-3654
Mailing Address - Fax:
Practice Address - Street 1:1790 SANSDAN CT
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-4738
Practice Address - Country:US
Practice Address - Phone:440-354-3654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP5580235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist