Provider Demographics
NPI:1003154691
Name:FETHERSON, BIANCA (PHD)
Entity Type:Individual
Prefix:DR
First Name:BIANCA
Middle Name:
Last Name:FETHERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7404 EXECUTIVE PL STE 225B
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-6205
Mailing Address - Country:US
Mailing Address - Phone:240-929-4387
Mailing Address - Fax:
Practice Address - Street 1:7404 EXECUTIVE PL STE 225B
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-6205
Practice Address - Country:US
Practice Address - Phone:240-929-4387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-17
Last Update Date:2019-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist