Provider Demographics
NPI:1285790972
Name:FISHER, GREGORY (CCDC-II)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:CCDC-II
Other - Prefix:
Other - First Name:GREG
Other - Middle Name:
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CCDC-II
Mailing Address - Street 1:PO BOX 447
Mailing Address - Street 2:11 EAST 4TH STREET
Mailing Address - City:LEMMON
Mailing Address - State:SD
Mailing Address - Zip Code:57638-0447
Mailing Address - Country:US
Mailing Address - Phone:605-374-3862
Mailing Address - Fax:605-374-3864
Practice Address - Street 1:11 4TH ST E
Practice Address - Street 2:
Practice Address - City:LEMMON
Practice Address - State:SD
Practice Address - Zip Code:57638-1524
Practice Address - Country:US
Practice Address - Phone:605-374-3862
Practice Address - Fax:605-374-3864
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD05121252OtherCERT. #