Provider Demographics
NPI:1194742817
Name:FITZMAURICE, KEVIN EVERETT (MS)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:EVERETT
Last Name:FITZMAURICE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3323 N 109TH PLZ
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-2908
Mailing Address - Country:US
Mailing Address - Phone:402-573-7277
Mailing Address - Fax:402-573-7360
Practice Address - Street 1:3323 N 109TH PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-2908
Practice Address - Country:US
Practice Address - Phone:402-573-7277
Practice Address - Fax:402-573-7360
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE745101YM0800X
IA00050101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA00050OtherLICENSED MENTAL HEALTH
NE33408OtherCCMHC
NE33408OtherNCC
NE10025178600Medicaid
NE745OtherMENTAL HEALTH PRACTITIONE
NE800OtherCERTIFIED PROFESSIONAL CO
NE10025178600Medicaid