Provider Demographics
NPI:1912475260
Name:DEEPER LIGHT PSYCHOTHERAPY
Entity Type:Organization
Organization Name:DEEPER LIGHT PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:DORIS
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:907-419-7048
Mailing Address - Street 1:174 S FRANKLIN ST STE 211
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-1362
Mailing Address - Country:US
Mailing Address - Phone:907-419-7048
Mailing Address - Fax:
Practice Address - Street 1:174 S FRANKLIN ST STE 211
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-1362
Practice Address - Country:US
Practice Address - Phone:907-419-7048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty