Provider Demographics
NPI:1902924590
Name:FITZGERALD, THERESA LYNN (DT)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:LYNN
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 S UNITY RD
Mailing Address - Street 2:
Mailing Address - City:POLO
Mailing Address - State:IL
Mailing Address - Zip Code:61064-9304
Mailing Address - Country:US
Mailing Address - Phone:815-946-3402
Mailing Address - Fax:815-946-3402
Practice Address - Street 1:6301 SOUTH UNITY ROAD
Practice Address - Street 2:
Practice Address - City:POLO
Practice Address - State:IL
Practice Address - Zip Code:61064-9304
Practice Address - Country:US
Practice Address - Phone:815-946-3402
Practice Address - Fax:815-946-3402
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
IL178002457101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist