Healthcare Provider Details

I. General information

NPI: 1326022104
Provider Name (Legal Business Name): EDWARD J. FITZPATRICK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 BARNETTE ST
FAIRBANKS AK
99701-4510
US

IV. Provider business mailing address

PO BOX 71544
FAIRBANKS AK
99707-1544
US

V. Phone/Fax

Practice location:
  • Phone: 907-456-4729
  • Fax: 907-456-4623
Mailing address:
  • Phone: 907-456-4729
  • Fax: 907-456-4623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberAA660
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: