Provider Demographics
NPI:1215476569
Name:FITZPATRICK, MARTINESE (MED, NCC, LPC)
Entity type:Individual
Prefix:
First Name:MARTINESE
Middle Name:
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:MED, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1916 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-4114
Mailing Address - Country:US
Mailing Address - Phone:662-281-1306
Mailing Address - Fax:662-281-1326
Practice Address - Street 1:1916 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-4114
Practice Address - Country:US
Practice Address - Phone:662-281-1306
Practice Address - Fax:662-281-1326
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2081101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2081OtherMISSISSIPPI BOARD OF EXAMINERS FOR LICENSED PROFESSIONALS