Provider Demographics
NPI:1922863877
Name:KIMBERLY FITZGERALD, LICSW INC
Entity Type:Organization
Organization Name:KIMBERLY FITZGERALD, LICSW INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & OPERATOR, CLINICAL SOCIAL W
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:508-364-1182
Mailing Address - Street 1:PO BOX 1393
Mailing Address - Street 2:
Mailing Address - City:SOUTH YARMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02664-7393
Mailing Address - Country:US
Mailing Address - Phone:508-364-1182
Mailing Address - Fax:
Practice Address - Street 1:6 GRANITE STATE CT UNIT 6
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:MA
Practice Address - Zip Code:02631-2127
Practice Address - Country:US
Practice Address - Phone:508-827-1220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000124707Medicaid
RIISW03846Medicaid