Provider Demographics
NPI:1386010189
Name:FITZGERALD, KATHLEEN MARIE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CONNETQUOT RD
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-2146
Mailing Address - Country:US
Mailing Address - Phone:631-563-9085
Mailing Address - Fax:
Practice Address - Street 1:202 CONNETQUOT RD
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-2146
Practice Address - Country:US
Practice Address - Phone:631-563-9085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-15
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
NY055004-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No104100000XBehavioral Health & Social Service ProvidersSocial Worker