Provider Demographics
NPI:1962088385
Name:FITZSIMMONS, JOHN (LCDCII)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:FITZSIMMONS
Suffix:
Gender:M
Credentials:LCDCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3140 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43209-2066
Mailing Address - Country:US
Mailing Address - Phone:614-754-8051
Mailing Address - Fax:
Practice Address - Street 1:4998 W BROAD ST STE 104
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1647
Practice Address - Country:US
Practice Address - Phone:614-754-8051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.174288101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)