Provider Demographics
NPI:1124308093
Name:DENISE M FICKLIN-FITZGERALD
Entity type:Organization
Organization Name:DENISE M FICKLIN-FITZGERALD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REHABILITATION CHRISTIAN COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FICKLIN-FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:EMBA
Authorized Official - Phone:888-666-1203
Mailing Address - Street 1:315 MADISON AVENUE
Mailing Address - Street 2:SUITE 901
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017
Mailing Address - Country:US
Mailing Address - Phone:888-666-1203
Mailing Address - Fax:212-957-1912
Practice Address - Street 1:315 MADISON AVE
Practice Address - Street 2:SUITE 901
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-5405
Practice Address - Country:US
Practice Address - Phone:888-666-1203
Practice Address - Fax:212-957-1912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY714520253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY251V00000XMedicaid
NY253Z00000XMedicaid
CA251V00000XMedicaid
NJ251V00000XMedicaid
CA253Z00000XMedicaid
CA251V00000XMedicare PIN
NY253Z00000XMedicaid
NY253Z00000XMedicare PIN
CA251V00000XMedicaid
NY251V00000XMedicare PIN