Provider Demographics
NPI:1629496179
Name:FITZGERALD, BRIAN (LMSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23040 ROSEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2230
Mailing Address - Country:US
Mailing Address - Phone:810-772-1954
Mailing Address - Fax:
Practice Address - Street 1:279 SUMMIT DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3364
Practice Address - Country:US
Practice Address - Phone:248-409-4308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010906251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical