Provider Demographics
NPI:1447784285
Name:FITZGERALD, JOHN (PHD, LPC, CAS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:PHD, LPC, CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 5TH ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3059
Mailing Address - Country:US
Mailing Address - Phone:503-343-5666
Mailing Address - Fax:
Practice Address - Street 1:450 5TH ST
Practice Address - Street 2:SUITE E
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3059
Practice Address - Country:US
Practice Address - Phone:503-343-5666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC-1322101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor