Provider Demographics
NPI:1528648078
Name:FISH, AUDREY JANE
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:JANE
Last Name:FISH
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 1:374 MERIDIAN PARKE LN
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-9406
Mailing Address - Country:US
Mailing Address - Phone:317-899-5437
Mailing Address - Fax:
Practice Address - Street 1:374 MERIDIAN PARKE LN
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-9406
Practice Address - Country:US
Practice Address - Phone:317-899-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20-140743106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician