Provider Demographics
NPI:1124395306
Name:FITZGERALD, MARY DORIS
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DORIS
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 LAWSON CREEK RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AK
Mailing Address - Zip Code:99824-5010
Mailing Address - Country:US
Mailing Address - Phone:801-860-4439
Mailing Address - Fax:
Practice Address - Street 1:2130 LAWSON CREEK RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AK
Practice Address - Zip Code:99824-5010
Practice Address - Country:US
Practice Address - Phone:801-860-4439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK802101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health