Provider Demographics
NPI:1588868277
Name:FITZGERALD, MARY ANN D (PC)
Entity type:Individual
Prefix:MS
First Name:MARY ANN
Middle Name:D
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:PC
Other - Prefix:MS
Other - First Name:MARY ANN
Other - Middle Name:
Other - Last Name:DAYTON-FITZGERALD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PC
Mailing Address - Street 1:415 SILAS DEANE HWY STE 220
Mailing Address - Street 2:A BALANCED LIFE COUNSELING CENTER, LLC
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-2119
Mailing Address - Country:US
Mailing Address - Phone:860-529-1696
Mailing Address - Fax:860-529-1696
Practice Address - Street 1:415 SILAS DEANE HWY STE 220
Practice Address - Street 2:A BALANCED LIFE COUNSELING CENTER, LLC
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-2119
Practice Address - Country:US
Practice Address - Phone:860-529-1696
Practice Address - Fax:860-529-1696
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000949101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT240000949CT02OtherANTHEM