Healthcare Provider Details

I. General information

NPI: 1669665717
Provider Name (Legal Business Name): STEPHANIE M. FITZGERALD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 SUMMER ST
SALEM MA
01970-3317
US

IV. Provider business mailing address

34 SUMMER ST
SALEM MA
01970-3317
US

V. Phone/Fax

Practice location:
  • Phone: 978-744-8608
  • Fax: 978-744-3702
Mailing address:
  • Phone: 978-744-8608
  • Fax: 978-744-3702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number117519
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number117519
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number117519
License Number StateMA

VIII. Authorized Official

Name: MS. STEPHANIE M FITZGERALD
Title or Position: PSYCHIATRIC CLINICAL NURSE
Credential: RN,MS,CS,PC
Phone: 978-744-8608