Provider Demographics
NPI:1669813317
Name:FITZGERALD, MARYELLEN (LADC)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 GRANGER ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4405
Mailing Address - Country:US
Mailing Address - Phone:802-775-8224
Mailing Address - Fax:802-747-7699
Practice Address - Street 1:135 GRANGER ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4405
Practice Address - Country:US
Practice Address - Phone:802-775-8224
Practice Address - Fax:802-747-7699
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000592101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT000592OtherLADC LICENSE