Provider Demographics
NPI:1558547679
Name:FITZGERALD, SALLY E (LMSW)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:E
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 ALLUMBAUGH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9210
Mailing Address - Country:US
Mailing Address - Phone:208-608-0256
Mailing Address - Fax:
Practice Address - Street 1:411 ALLUMBAUGH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9210
Practice Address - Country:US
Practice Address - Phone:208-608-0256
Practice Address - Fax:208-322-4722
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW 1493101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health