Provider Demographics
NPI:1245635812
Name:FITZGERALD, VINCENT JOHN (LSW)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:JOHN
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 SIP AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-6511
Mailing Address - Country:US
Mailing Address - Phone:201-400-9156
Mailing Address - Fax:
Practice Address - Street 1:155 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-2311
Practice Address - Country:US
Practice Address - Phone:973-667-1184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05372900104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker