Provider Demographics
NPI:1437540291
Name:FITZGERALD, WILLIAM (PHD)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
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 1:4224 BEECHMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-9520
Mailing Address - Country:US
Mailing Address - Phone:269-267-4758
Mailing Address - Fax:269-312-8972
Practice Address - Street 1:1919 STEARNS AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008
Practice Address - Country:US
Practice Address - Phone:269-224-1545
Practice Address - Fax:269-312-8972
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-13
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103T00000X
MI6301015893103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist