1124308093 NPI number — DENISE M FICKLIN-FITZGERALD

Table of content: (NPI 1124308093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124308093 NPI number — DENISE M FICKLIN-FITZGERALD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENISE M FICKLIN-FITZGERALD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124308093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
315 MADISON AVENUE
Provider Second Line Business Mailing Address:
SUITE 901
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-666-1203
Provider Business Mailing Address Fax Number:
212-957-1912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 MADISON AVE
Provider Second Line Business Practice Location Address:
SUITE 901
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10017-5405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-666-1203
Provider Business Practice Location Address Fax Number:
212-957-1912
Provider Enumeration Date:
08/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
FICKLIN-FITZGERALD
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
REHABILITATION CHRISTIAN COUNSELOR
Authorized Official Telephone Number:
888-666-1203

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , with the licence number:  714520 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 251V00000X , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 253Z00000X , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 251V00000X , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 251V00000X , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 253Z00000X , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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