=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396511804
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETHANY ADAIR FITZSIMMONS LCSW-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2023
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2A LAI RESIDENCE 8F NO. 1, LANE 91 SHI-DONG ROAD
-----------------------------------------------------
City | TAIPEI
-----------------------------------------------------
State | TAIPEI
-----------------------------------------------------
Zip | 111034
-----------------------------------------------------
Country | TW
-----------------------------------------------------
Telephone | 410-935-8702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | UNIT 4170 BOX 169
-----------------------------------------------------
City | DPO
-----------------------------------------------------
State | AE
-----------------------------------------------------
Zip | 09862-0169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-768-7277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 24835
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------