Provider Demographics
NPI:1174843130
Name:FETSKO, JUSTIN MATTHEW (DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MATTHEW
Last Name:FETSKO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 HEALTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-1907
Mailing Address - Country:US
Mailing Address - Phone:334-699-5747
Mailing Address - Fax:
Practice Address - Street 1:348 HEALTHWEST DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-1907
Practice Address - Country:US
Practice Address - Phone:334-699-5747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-01
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH5315225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist