Provider Demographics
NPI:1013253400
Name:FITZGERALD, BRIAN (LPC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2414 W CHAPEL RIM CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-7922
Mailing Address - Country:US
Mailing Address - Phone:801-313-7680
Mailing Address - Fax:
Practice Address - Street 1:5770 S 1500 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-5216
Practice Address - Country:US
Practice Address - Phone:801-313-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT275288-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional