Provider Demographics
NPI:1457036790
Name:FITZSIMONDS, KEALIE MORGAN (LAPC)
Entity Type:Individual
Prefix:
First Name:KEALIE
Middle Name:MORGAN
Last Name:FITZSIMONDS
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 32ND AVE W # ENVY423
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-2898
Mailing Address - Country:US
Mailing Address - Phone:701-520-5580
Mailing Address - Fax:
Practice Address - Street 1:3220 4TH ST E STE 102
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-3082
Practice Address - Country:US
Practice Address - Phone:701-501-7449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1288-6-1-23A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty