Provider Demographics
NPI:1013461656
Name:FITZGERALD, KAYLIN
Entity type:Individual
Prefix:
First Name:KAYLIN
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22795 KIOWA CT
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-6412
Mailing Address - Country:US
Mailing Address - Phone:951-489-8897
Mailing Address - Fax:
Practice Address - Street 1:125 W F ST
Practice Address - Street 2:STE 101
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3201
Practice Address - Country:US
Practice Address - Phone:909-986-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)