Provider Demographics
NPI:1902819436
Name:FITZGERALD, LORA SERAPHIN (MA, ATC)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:SERAPHIN
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5524 LA BANDERA TRL
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76126-1843
Mailing Address - Country:US
Mailing Address - Phone:337-212-3849
Mailing Address - Fax:
Practice Address - Street 1:1651 W ROSEDALE ST
Practice Address - Street 2:STE. 200
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7437
Practice Address - Country:US
Practice Address - Phone:817-335-4316
Practice Address - Fax:817-336-2504
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
050202041OtherNATABOC