Provider Demographics
NPI:1083169643
Name:FITZGERALD, TAMARA (MSOT)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 21324
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-0989
Mailing Address - Country:US
Mailing Address - Phone:619-770-8198
Mailing Address - Fax:
Practice Address - Street 1:225 W MADISON AVE # 3
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3454
Practice Address - Country:US
Practice Address - Phone:619-667-6031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT15759225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist