Provider Demographics
NPI:1639502602
Name:FITZGERALD, MARY
Entity Type:Individual
Prefix:
First Name:MARY
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 1:11240 WAPLES MILL RD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6078
Mailing Address - Country:US
Mailing Address - Phone:703-383-6454
Mailing Address - Fax:703-810-5494
Practice Address - Street 1:1635 N GEORGE MASON DR
Practice Address - Street 2:SUITE 110
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3601
Practice Address - Country:US
Practice Address - Phone:703-810-5216
Practice Address - Fax:703-810-5494
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305208220225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist