Provider Demographics
NPI:1669082657
Name:FITZGERALD, SHANE
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-5007
Mailing Address - Country:US
Mailing Address - Phone:781-686-0637
Mailing Address - Fax:
Practice Address - Street 1:131 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-7005
Practice Address - Country:US
Practice Address - Phone:781-686-0637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASLP78075235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist