Provider Demographics
NPI:1356490361
Name:FITZGERALD, DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 KANE ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-2110
Mailing Address - Country:US
Mailing Address - Phone:860-523-3745
Mailing Address - Fax:860-523-3736
Practice Address - Street 1:65 KANE ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-2110
Practice Address - Country:US
Practice Address - Phone:860-523-3745
Practice Address - Fax:860-523-3736
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2274103TC0700X
CT003752103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTH000Medicare ID - Type Unspecified
NC6000284Medicare ID - Type Unspecified
NC2820134Medicare ID - Type Unspecified