=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518556984
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLARA FITZSIMMONS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2021
-----------------------------------------------------
Last Update Date | 01/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11260 RANCH CREEK TER APT 118
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34211-4032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-291-1294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11260 RANCH CREEK TER APT 118
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34211-4032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-291-1294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | SS1456
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------