Healthcare Provider Details

I. General information

NPI: 1306511712
Provider Name (Legal Business Name): DEMI RAYE FITZPATRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3491 KURTZ ST # 150
SAN DIEGO CA
92110-4430
US

IV. Provider business mailing address

3491 KURTZ ST # 150
SAN DIEGO CA
92110-4430
US

V. Phone/Fax

Practice location:
  • Phone: 619-320-2404
  • Fax:
Mailing address:
  • Phone: 619-320-2404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number111280
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: