MEDICARE: FITZGERALD TARDIEU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

General Provider Information

NPI Number	:	1750175105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FITZGERALD TARDIEU

Provider Business Mailing Address
First Line	:	21828 104TH AVE
Second Line	:
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11429-2051
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	21828 104TH AVE
Second Line	:
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11429-2051
Country	:	US
Telephone Number	:	347-530-8503
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2025
Last Update Date	:	04/08/2025

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Directions to “ FITZGERALD TARDIEU ” Practice Location

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