Provider Demographics
NPI:1669415139
Name:FITZGERALD, DENISE MARY (LCSW)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:MARY
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6430
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72766-6430
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:479-845-2109
Practice Address - Street 1:2205 PHYLLIS ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-6490
Practice Address - Country:US
Practice Address - Phone:479-750-2020
Practice Address - Fax:479-845-2109
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1761-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X504OtherBLUE SHIELD PROVIDER #