Basic Information
| Provider Information | |||||||||
| NPI: | 1508151846 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FITTS | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1097 DORADO DR | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320867086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074084800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1750 TREE BLVD | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320845715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043420672 | ||||||||
| FaxNumber: | 9043420673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2011 | ||||||||
| LastUpdateDate: | 06/17/2011 | ||||||||
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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 | 1041C0700X | SW9608 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.