Provider Demographics
NPI:1326022104
Name:FITZPATRICK, EDWARD J (LCSW)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:FITZPATRICK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 71544
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-1544
Mailing Address - Country:US
Mailing Address - Phone:907-456-4729
Mailing Address - Fax:907-456-4623
Practice Address - Street 1:912 BARNETTE ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4510
Practice Address - Country:US
Practice Address - Phone:907-456-4729
Practice Address - Fax:907-456-4623
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA6601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK160267Medicare PIN