Provider Demographics
NPI:1710943162
Name:FITZGERALD, SUSAN KAY (CPCI MS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:CPCI MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:548 E 8000 S
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070
Mailing Address - Country:US
Mailing Address - Phone:801-703-4055
Mailing Address - Fax:
Practice Address - Street 1:3809 S WEST TEMPLE
Practice Address - Street 2:1B
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115
Practice Address - Country:US
Practice Address - Phone:801-268-4454
Practice Address - Fax:801-268-2176
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56661986009101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor