Provider Demographics
NPI:1417004714
Name:FITZGERALD, COREY (MSW MPH)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:MSW MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USAMEDDAC WUERZBURG
Mailing Address - Street 2:ATTN CREDENTIALS UNIT 26610
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09244
Mailing Address - Country:DE
Mailing Address - Phone:01149931-804-3616
Mailing Address - Fax:01149931-804-3241
Practice Address - Street 1:USAMEDDAC WUERZBURG
Practice Address - Street 2:HOHENFELS
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09173
Practice Address - Country:DE
Practice Address - Phone:01149947-283-1710
Practice Address - Fax:01149947-283-2844
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI93741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN