Provider Demographics
NPI:1679630222
Name:FISH, JULIENNE DAVIDGE (MA, LLP)
Entity type:Individual
Prefix:MRS
First Name:JULIENNE
Middle Name:DAVIDGE
Last Name:FISH
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30524 MCGRATH DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-5611
Mailing Address - Country:US
Mailing Address - Phone:586-582-0063
Mailing Address - Fax:
Practice Address - Street 1:2825 LIVERNOIS RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1214
Practice Address - Country:US
Practice Address - Phone:248-680-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361005162103T00000X
MI6301009310103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical