Provider Demographics
NPI:1841457009
Name:FITZGERALD, GWEN M (LMSW)
Entity type:Individual
Prefix:MS
First Name:GWEN
Middle Name:M
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 FRANKLIN STREET
Mailing Address - Street 2:LAKE SHORE BEHAVIORAL HEALTH
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202
Mailing Address - Country:US
Mailing Address - Phone:716-842-0440
Mailing Address - Fax:716-842-4069
Practice Address - Street 1:625 DELAWARE AVENUE
Practice Address - Street 2:LINWOOD COMMUNITY SERVICES
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202
Practice Address - Country:US
Practice Address - Phone:716-882-3151
Practice Address - Fax:716-886-4002
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076460-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY076460-1OtherLMSW