Provider Demographics
NPI:1154078640
Name:FITZGERALD, MARY THERESA (LMFT)
Entity Type:Individual
Prefix:
First Name:MARY THERESA
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 RIDGE AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1660
Mailing Address - Country:US
Mailing Address - Phone:215-290-2634
Mailing Address - Fax:
Practice Address - Street 1:6060 RIDGE AVE STE 210
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1660
Practice Address - Country:US
Practice Address - Phone:215-290-2634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMF001385106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist