Healthcare Provider Details

I. General information

NPI: 1790710150
Provider Name (Legal Business Name): CAROL J FITZPATRICK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 04/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 APACHE AVE
SANTA FE NM
87505-3255
US

IV. Provider business mailing address

1800 OLD PECOS TRL STE B
SANTA FE NM
87505-4787
US

V. Phone/Fax

Practice location:
  • Phone: 505-424-9159
  • Fax: 505-216-7595
Mailing address:
  • Phone: 505-424-9159
  • Fax: 505-216-7595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0769
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: