Provider Demographics
NPI:1538201322
Name:FITZPATRICK, PHILLIP DAVID (LCSW)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:DAVID
Last Name:FITZPATRICK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 HARVEST LN
Mailing Address - Street 2:
Mailing Address - City:MC GREGOR
Mailing Address - State:TX
Mailing Address - Zip Code:76657-9713
Mailing Address - Country:US
Mailing Address - Phone:254-722-6247
Mailing Address - Fax:
Practice Address - Street 1:6600 SANGER AVE
Practice Address - Street 2:SUITE # 9
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-7814
Practice Address - Country:US
Practice Address - Phone:254-722-6247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16268104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103097504Medicaid