Healthcare Provider Details

I. General information

NPI: 1740492669
Provider Name (Legal Business Name): MELISA FITZGERALD LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 SAN ANSELMO
BIG BEAR CITY CA
92314
US

IV. Provider business mailing address

PO BOX 3235
BIG BEAR CITY CA
92314-3235
US

V. Phone/Fax

Practice location:
  • Phone: 909-645-8191
  • Fax:
Mailing address:
  • Phone: 909-645-8191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF52675
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 46520
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: