Provider Demographics
NPI:1790710150
Name:FITZPATRICK, CAROL J (PHD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:J
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1800 OLD PECOS TRL STE B
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4787
Mailing Address - Country:US
Mailing Address - Phone:505-424-9159
Mailing Address - Fax:505-216-7595
Practice Address - Street 1:1232 APACHE AVE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3255
Practice Address - Country:US
Practice Address - Phone:505-424-9159
Practice Address - Fax:505-216-7595
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0769103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM600536OtherVALUE OPTIONS
NM201030542OtherPRESBYTERIAN HEALTH PLAN