Provider Demographics
NPI:1114447026
Name:FITZGERALD, BRENDA MARIE (MT123835)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:MARIE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:MT123835
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S CENTRAL EXPY STE 43
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-6314
Mailing Address - Country:US
Mailing Address - Phone:214-566-9894
Mailing Address - Fax:
Practice Address - Street 1:100 S. CENTRAL EXPRESSWAY
Practice Address - Street 2:#43
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080
Practice Address - Country:US
Practice Address - Phone:214-566-9894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT123835225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist