Provider Demographics
NPI:1568728020
Name:FITZGIBBONS, MICHELE (LMT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:FITZGIBBONS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 HARVEST AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-3049
Mailing Address - Country:US
Mailing Address - Phone:917-578-5712
Mailing Address - Fax:
Practice Address - Street 1:33 RICHMOND HILL RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-5950
Practice Address - Country:US
Practice Address - Phone:718-982-6340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27 017932225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist