Provider Demographics
NPI:1952542458
Name:FITZGERALD, THAMARA DAYMIEL (PT)
Entity Type:Individual
Prefix:MRS
First Name:THAMARA
Middle Name:DAYMIEL
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 N 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1805
Mailing Address - Country:US
Mailing Address - Phone:708-681-6334
Mailing Address - Fax:
Practice Address - Street 1:444 N WELLS ST STE 304
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-4593
Practice Address - Country:US
Practice Address - Phone:312-494-9936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009886174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist