Healthcare Provider Details

I. General information

NPI: 1679752562
Provider Name (Legal Business Name): MARY FITZGIBBONS PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12125 WOODCREST EXECUTIVE DR
SAINT LOUIS MO
63141-5001
US

IV. Provider business mailing address

12125 WOODCREST EXECUTIVE DR
SAINT LOUIS MO
63141-5001
US

V. Phone/Fax

Practice location:
  • Phone: 314-275-8599
  • Fax:
Mailing address:
  • Phone: 314-275-8599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number00944
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: