Provider Demographics
NPI:1144391954
Name:FITZGERALD, THOMAS J (MED)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 CRAGMERE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-4928
Mailing Address - Country:US
Mailing Address - Phone:207-799-1758
Mailing Address - Fax:
Practice Address - Street 1:95 EXCHANGE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-5037
Practice Address - Country:US
Practice Address - Phone:207-871-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC460 LMFT461101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional