1215908058 NPI number — MARY TRABUE FITZGERALD CCC-SLP, CCC-A

Table of content: MARY TRABUE FITZGERALD CCC-SLP, CCC-A (NPI 1215908058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215908058 NPI number — MARY TRABUE FITZGERALD CCC-SLP, CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZGERALD
Provider First Name:
MARY
Provider Middle Name:
TRABUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CCC-SLP, CCC-A
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1215908058
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3704 SYCAMORE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37215-1914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-292-4741
Provider Business Mailing Address Fax Number:
615-385-2785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3704 SYCAMORE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37215-1914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-292-4741
Provider Business Practice Location Address Fax Number:
615-385-2785
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  55 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 235Z00000X , with the licence number: 291 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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