Provider Demographics
NPI:1255577797
Name:FISK, PETER C (PHD, LMHC)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:C
Last Name:FISK
Suffix:
Gender:M
Credentials:PHD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 CALLE DEL SOL
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-9209
Mailing Address - Country:US
Mailing Address - Phone:505-565-1619
Mailing Address - Fax:505-565-1620
Practice Address - Street 1:303 LUNA ST SE
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-9277
Practice Address - Country:US
Practice Address - Phone:505-565-1619
Practice Address - Fax:505-565-1620
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0118651101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor