Provider Demographics
NPI:1669400065
Name:PEEK-FISK, ROLANDA SUE (LCSW)
Entity type:Individual
Prefix:
First Name:ROLANDA
Middle Name:SUE
Last Name:PEEK-FISK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-2223
Mailing Address - Country:US
Mailing Address - Phone:270-251-3666
Mailing Address - Fax:270-251-3506
Practice Address - Street 1:229 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-2223
Practice Address - Country:US
Practice Address - Phone:270-251-3666
Practice Address - Fax:270-251-3506
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY766101YM0800X
TNLSW0000003337101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY82000746Medicaid
KY0763401Medicare ID - Type Unspecified
KY82000746Medicaid