Provider Demographics
NPI:1174853964
Name:FITZGERALD, MICAELA THARP (LPC)
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:THARP
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 S MEDFORD DR
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901-5633
Mailing Address - Country:US
Mailing Address - Phone:936-633-5676
Mailing Address - Fax:936-633-5695
Practice Address - Street 1:4101 S MEDFORD DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-5633
Practice Address - Country:US
Practice Address - Phone:936-633-5676
Practice Address - Fax:936-633-5695
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-30
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63453101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional