Provider Demographics
NPI:1841907508
Name:FISK, TERRA
Entity type:Individual
Prefix:
First Name:TERRA
Middle Name:
Last Name:FISK
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 1:1009 3RD AVE N
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-1507
Mailing Address - Country:US
Mailing Address - Phone:406-452-6400
Mailing Address - Fax:406-452-2250
Practice Address - Street 1:1009 3RD AVE N
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-1507
Practice Address - Country:US
Practice Address - Phone:406-452-6400
Practice Address - Fax:406-452-2250
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT000000023310400000X
MT0000000023251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0001616496Medicaid
MT0001616496OtherAPI