Basic Information
| Provider Information | |||||||||
| NPI: | 1861086241 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITZPATRICK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | LANELL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AAC, CPC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2394 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986328455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602005419 | ||||||||
| FaxNumber: | 3602006736 | ||||||||
| Practice Location | |||||||||
| Address1: | 1408 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986323822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609983050 | ||||||||
| FaxNumber: | 3602006736 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2021 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | WA | N | Behavioral Health & Social Service Providers | Counselor | 171M00000X | WA | N | Other Service Providers | Case Manager/Care Coordinator | 175T00000X | CG61163067 | WA | Y |
ID Information
| ID | Type | State | Issuer | Description | 2176426 | 05 | WA | MEDICAID |