Provider Demographics
NPI:1114001971
Name:FITZGERALD, MARY W (LCSW, CAC III)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:W
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:LCSW, CAC III
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:W
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1349 LINDENROSE GROVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907
Mailing Address - Country:US
Mailing Address - Phone:719-548-0100
Mailing Address - Fax:719-548-0616
Practice Address - Street 1:5540 TECH CENTER DR
Practice Address - Street 2:SPRINGS COUNSELING CENTER, #203
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-2331
Practice Address - Country:US
Practice Address - Phone:719-548-0100
Practice Address - Fax:719-548-0616
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9918991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO804973Medicare ID - Type Unspecified