Basic Information
| Provider Information | |||||||||
| NPI: | 1417201641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITZGERALD | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | IRENE | ||||||||
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| Credential: | MFTI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 MISSION ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941032417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152261775 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1735 MISSION ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941032417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152261775 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2012 | ||||||||
| LastUpdateDate: | 11/09/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF66730 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.