Provider Demographics
NPI:1124415203
Name:FETTY, TERA (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:
Last Name:FETTY
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:TERA
Other - Middle Name:
Other - Last Name:MCDOUGAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7178 BUCKHANNON PIKE
Mailing Address - Street 2:APT. 4
Mailing Address - City:MOUNT CLARE
Mailing Address - State:WV
Mailing Address - Zip Code:26408-6917
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6040 UNIVERSITY TOWN CENTRE DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-2421
Practice Address - Country:US
Practice Address - Phone:304-598-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAT0010182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer