Provider Demographics
NPI:1346097458
Name:FITZWILLIAM, JOHN (BA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:FITZWILLIAM
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1280 E GOLFVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-3108
Mailing Address - Country:US
Mailing Address - Phone:954-669-4229
Mailing Address - Fax:
Practice Address - Street 1:5420 NW 33RD AVE STE 101
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-6348
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:772-675-9100
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician