Provider Demographics
NPI:1366192452
Name:FISHER, MICHAEL JACOB (CSAC-S,)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JACOB
Last Name:FISHER
Suffix:
Gender:M
Credentials:CSAC-S,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 LONGVIEW AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-1614
Mailing Address - Country:US
Mailing Address - Phone:603-978-9032
Mailing Address - Fax:
Practice Address - Street 1:3208 HERSHBERGER RD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-1842
Practice Address - Country:US
Practice Address - Phone:540-202-2402
Practice Address - Fax:540-563-3084
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty