Provider Demographics
NPI:1659095362
Name:FITZGERALD, NICOLE
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
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 1:750 RANSOM RD
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-8973
Mailing Address - Country:US
Mailing Address - Phone:219-850-1971
Mailing Address - Fax:219-548-8064
Practice Address - Street 1:750 RANSOM RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-8973
Practice Address - Country:US
Practice Address - Phone:219-850-1971
Practice Address - Fax:219-548-8064
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1482886103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool