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General NPI Number Information
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NPI Number | 1902924590
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Entity Type | Individual
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Provider Name | THERESA LYNN FITZGERALD D.T.
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Gender | Female
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 12/03/2019
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Provider Practice Location Address
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Address Line | 6301 SOUTH UNITY ROAD
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City | POLO
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State | IL
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Zip | 61064-9304
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Country | US
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Telephone | 815-946-3402
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Fax | 815-946-3402
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Provider Business Mailing Address
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Address Line | 6301 S UNITY RD
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City | POLO
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State | IL
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Zip | 61064-9304
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Country | US
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Telephone | 815-946-3402
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Fax | 815-946-3402
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 222Q00000X
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Taxonomy Name | Developmental Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 178002457
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License Number State | IL
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