Provider Demographics
NPI:1265835680
Name:FITZGERALD, CHRISTINE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:ROACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 PEACHTREE CT
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4616
Mailing Address - Country:US
Mailing Address - Phone:631-467-3700
Mailing Address - Fax:631-467-0928
Practice Address - Street 1:140 WASHINGTON AVENUE EXT
Practice Address - Street 2:APT D58
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-5399
Practice Address - Country:US
Practice Address - Phone:518-869-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009563225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist