Provider Demographics
NPI:1558635078
Name:FITZSIMMONS, MARY ROBINETTE H (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY ROBINETTE
Middle Name:H
Last Name:FITZSIMMONS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 NW VAUGHN ST
Mailing Address - Street 2:STE 140
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5311
Mailing Address - Country:US
Mailing Address - Phone:503-499-5200
Mailing Address - Fax:877-477-2329
Practice Address - Street 1:2701 NW VAUGHN ST
Practice Address - Street 2:STE 140
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5311
Practice Address - Country:US
Practice Address - Phone:503-499-5200
Practice Address - Fax:877-477-2329
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL42441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORL4244OtherOREGON STATE BOARD OF LICENSED SOCIAL WORKERS
WACG60145984OtherWASHINGTON STATE DEPARTMENT OF HEALTH