Provider Demographics
NPI:1992889281
Name:FISHER, MARYKAY (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARYKAY
Middle Name:
Last Name:FISHER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5702 BALTIMORE DR
Mailing Address - Street 2:UNIT 275
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-1691
Mailing Address - Country:US
Mailing Address - Phone:715-222-1235
Mailing Address - Fax:
Practice Address - Street 1:8080 LA MESA BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-0377
Practice Address - Country:US
Practice Address - Phone:715-222-1235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25344103TC0700X
WI2325-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB228837Medicare UPIN