Provider Demographics
NPI:1619015781
Name:FITZELLE, CONSTANCE PIERSON (MA2 MS1)
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:PIERSON
Last Name:FITZELLE
Suffix:
Gender:F
Credentials:MA2 MS1
Other - Prefix:MRS
Other - First Name:CONSTANCE
Other - Middle Name:D
Other - Last Name:PIERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13 LINDEN DR
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02881
Mailing Address - Country:US
Mailing Address - Phone:401-783-7749
Mailing Address - Fax:
Practice Address - Street 1:13 LINDEN DR
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:RI
Practice Address - Zip Code:02881
Practice Address - Country:US
Practice Address - Phone:401-783-7749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI#33MFT106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0552267742Medicare ID - Type Unspecified