Healthcare Provider Details

I. General information

NPI: 1245930387
Provider Name (Legal Business Name): KEVIN S FITZGERALD LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3747 W WRIGHTWOOD AVE FL 1
CHICAGO IL
60647-1150
US

IV. Provider business mailing address

3747 W WRIGHTWOOD AVE FL 1
CHICAGO IL
60647-1150
US

V. Phone/Fax

Practice location:
  • Phone: 630-621-5911
  • Fax:
Mailing address:
  • Phone: 630-621-5911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.017255
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.017255
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: