=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285160192
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIDGET FITZGERALD LISW-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2017
-----------------------------------------------------
Last Update Date | 10/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2525 E 22ND ST
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44115-3202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-320-8334
-----------------------------------------------------
Fax | 213-320-8737
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22001 FAIRMOUNT BLVD
-----------------------------------------------------
City | SHAKER HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44118-4819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-320-8334
-----------------------------------------------------
Fax | 213-320-8737
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I.1500062-SUPV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I1500062
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------