Provider Demographics
NPI:1912491069
Name:FISHER, JULIA GRACE (ATR-BC)
Entity Type:Individual
Prefix:MRS
First Name:JULIA
Middle Name:GRACE
Last Name:FISHER
Suffix:
Gender:F
Credentials:ATR-BC
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:
Other - Last Name:WIBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6180 VANDERBILT AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-3332
Mailing Address - Country:US
Mailing Address - Phone:562-896-8673
Mailing Address - Fax:
Practice Address - Street 1:6180 VANDERBILT AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-3332
Practice Address - Country:US
Practice Address - Phone:562-896-8673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA17-264221700000X
PAPC011302101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist