Provider Demographics
NPI:1457490559
Name:FITTS, MARY ELLEN (MSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:FITTS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4941 COUNTY ROAD Z
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095
Mailing Address - Country:US
Mailing Address - Phone:262-677-0735
Mailing Address - Fax:
Practice Address - Street 1:W62 N248 WASHINGTON AVENUE
Practice Address - Street 2:SUITE #207
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012
Practice Address - Country:US
Practice Address - Phone:262-375-1116
Practice Address - Fax:262-375-1071
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20011231041C0700X
WI198124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39254400Medicaid