Provider Demographics
NPI:1083745517
Name:FETTER, DAVID OWEN
Entity Type:Individual
Prefix:PROF
First Name:DAVID
Middle Name:OWEN
Last Name:FETTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 S PATAGONIA ST
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85602-6533
Mailing Address - Country:US
Mailing Address - Phone:520-586-2213
Mailing Address - Fax:
Practice Address - Street 1:360 S PATAGONIA ST
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:AZ
Practice Address - Zip Code:85602-6533
Practice Address - Country:US
Practice Address - Phone:520-586-2213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL5289235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZSLPL5289OtherSPEECH PATHOLOGIST LICENS