Provider Demographics
NPI:1457036790
Name:FITZSIMONDS, KEALIE MORGAN (LAPC)
Entity type:Individual
Prefix:
First Name:KEALIE
Middle Name:MORGAN
Last Name:FITZSIMONDS
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 18TH ST S
Mailing Address - Street 2:STE B
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104
Mailing Address - Country:US
Mailing Address - Phone:701-205-7771
Mailing Address - Fax:701-205-3798
Practice Address - Street 1:3210 18TH ST S
Practice Address - Street 2:STE B
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104
Practice Address - Country:US
Practice Address - Phone:701-205-7771
Practice Address - Fax:701-205-3798
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1288-6-1-23A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty