Provider Demographics
NPI:1942562095
Name:FITZGERALD, SHANNON MARIE (MA)
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:MARIE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:597 THIRD AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12182
Mailing Address - Country:US
Mailing Address - Phone:518-233-0544
Mailing Address - Fax:518-233-0703
Practice Address - Street 1:597 3RD AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12182-2509
Practice Address - Country:US
Practice Address - Phone:518-233-0544
Practice Address - Fax:518-233-0703
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY463013101252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency