Provider Demographics
NPI:1457300121
Name:FITZGIBBON, MARIAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARIAN
Middle Name:
Last Name:FITZGIBBON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1747 W ROOSEVELT RD
Mailing Address - Street 2:SUITE 586
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1264
Mailing Address - Country:US
Mailing Address - Phone:312-996-0146
Mailing Address - Fax:312-413-8950
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-996-0146
Practice Address - Fax:312-413-8950
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical