Provider Demographics
NPI:1861086241
Name:FITZPATRICK, JOHN LANELL (AAC, CPC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LANELL
Last Name:FITZPATRICK
Suffix:
Gender:M
Credentials:AAC, CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2394
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8455
Mailing Address - Country:US
Mailing Address - Phone:360-200-5419
Mailing Address - Fax:360-200-6736
Practice Address - Street 1:1408 12TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3822
Practice Address - Country:US
Practice Address - Phone:360-998-3050
Practice Address - Fax:360-200-6736
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101Y00000X, 171M00000X
WACG61163067175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2176426Medicaid