Provider Demographics
NPI:1255526356
Name:FITZGIBBON, MARISSA LYNN
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:LYNN
Last Name:FITZGIBBON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:LYNN
Other - Last Name:FERNANDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22505 WOODROE AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-3410
Mailing Address - Country:US
Mailing Address - Phone:510-613-0330
Mailing Address - Fax:
Practice Address - Street 1:1 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAN QUENTIN
Practice Address - State:CA
Practice Address - Zip Code:94964-1000
Practice Address - Country:US
Practice Address - Phone:415-454-1460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CA292261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker