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General NPI Number Information
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NPI Number | 1861792723
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Entity Type | Organization
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Legal Business Name | FITZGIBBONS PSYCHOLOGICAL WEST COUNTY PSYCHOLOGICAL ASSOCIATES
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Dates
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Enumeration Date | 10/26/2010
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Last Update Date | 04/14/2015
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Provider Practice Location Address
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Address Line | 12125 WOODCREST EXECUTIVE DR
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City | SAINT LOUIS
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State | MO
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Zip | 63141-5001
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Country | US
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Telephone | 314-275-8599
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Fax |
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Provider Business Mailing Address
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Address Line | 12125 WOODCREST EXECUTIVE DR
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City | SAINT LOUIS
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State | MO
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Zip | 63141-5001
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Country | US
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Telephone | 314-275-8599
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. MARY FITZGIBBONS
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Credential |
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Telephone | 314-275-8599
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 00944
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License Number State | MO
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