Provider Demographics
NPI:1003439340
Name:FETTER, VICTORIA
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:FETTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 S ELDORADO RD STE 102
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-6075
Mailing Address - Country:US
Mailing Address - Phone:888-428-7890
Mailing Address - Fax:877-428-7891
Practice Address - Street 1:808 S ELDORADO RD STE 102
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6075
Practice Address - Country:US
Practice Address - Phone:888-428-7890
Practice Address - Fax:877-428-7891
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IL180.015113101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370915481007Medicaid