Provider Demographics
NPI:1174815922
Name:FISHAUT, REBECCA M (LICSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:M
Last Name:FISHAUT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 NW 54TH ST STE 334
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-3571
Mailing Address - Country:US
Mailing Address - Phone:425-954-7473
Mailing Address - Fax:844-308-5012
Practice Address - Street 1:1417 NW 54TH ST STE 334
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-3571
Practice Address - Country:US
Practice Address - Phone:425-954-7473
Practice Address - Fax:844-308-5012
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW602052761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2074080Medicaid