Provider Demographics
NPI:1578965182
Name:FITZGERALD, CHARLEEN
Entity Type:Individual
Prefix:
First Name:CHARLEEN
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17210 91ST AVE E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-2235
Mailing Address - Country:US
Mailing Address - Phone:253-222-5012
Mailing Address - Fax:
Practice Address - Street 1:12812 101ST AVENUE CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-9101
Practice Address - Country:US
Practice Address - Phone:253-864-4770
Practice Address - Fax:253-864-4771
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP 00004295101YA0400X
WAMC60323125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health