Provider Demographics
NPI:1760572432
Name:FITZGERALD, CHERYL G
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:G
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 1:14240 SAND PINE LN
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32409-2559
Mailing Address - Country:US
Mailing Address - Phone:850-265-5152
Mailing Address - Fax:850-265-5152
Practice Address - Street 1:14240 SAND PINE LN
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32409-2559
Practice Address - Country:US
Practice Address - Phone:850-265-5152
Practice Address - Fax:850-265-5152
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL760632000Medicaid