Provider Demographics
NPI:1790007250
Name:FITZGERALD, MARYLIN (MA LLP)
Entity Type:Individual
Prefix:
First Name:MARYLIN
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 S UNION ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-3247
Mailing Address - Country:US
Mailing Address - Phone:231-941-6550
Mailing Address - Fax:231-941-8981
Practice Address - Street 1:512 S UNION ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3247
Practice Address - Country:US
Practice Address - Phone:231-941-6550
Practice Address - Fax:231-941-8981
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002079103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling