Provider Demographics
NPI:1255945135
Name:FITZGIBBON, KIMBERLY ETHRIDGE (PHD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ETHRIDGE
Last Name:FITZGIBBON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02030-2205
Mailing Address - Country:US
Mailing Address - Phone:617-645-8745
Mailing Address - Fax:
Practice Address - Street 1:26 CHESTNUT ST STE 2E
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3600
Practice Address - Country:US
Practice Address - Phone:978-749-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist