Provider Demographics
NPI:1972850071
Name:FITZGERALD, MISTY L (LMSW-CC)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:L
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 ELM ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5380
Mailing Address - Country:US
Mailing Address - Phone:207-323-1635
Mailing Address - Fax:
Practice Address - Street 1:40 SUMMER ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6446
Practice Address - Country:US
Practice Address - Phone:207-323-1635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC137271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical