Provider Demographics
NPI:1699002089
Name:FITZSIMMONS, CYNTHIA R (PSYD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:R
Last Name:FITZSIMMONS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 WALNUT ST STE 107
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-4063
Mailing Address - Country:US
Mailing Address - Phone:910-805-8205
Mailing Address - Fax:
Practice Address - Street 1:313 WALNUT ST STE 107
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4063
Practice Address - Country:US
Practice Address - Phone:910-805-8205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1136103G00000X, 103TC0700X
NC3855103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0469Medicaid
SCPS0469Medicaid