Provider Demographics
NPI:1235591140
Name:FITZSIMMONS, MARK (LPC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:FITZSIMMONS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 NANTUCKET AVE
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2504
Mailing Address - Country:US
Mailing Address - Phone:361-649-0740
Mailing Address - Fax:
Practice Address - Street 1:204 NANTUCKET AVE
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2504
Practice Address - Country:US
Practice Address - Phone:361-649-0740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16202101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional