Provider Demographics
NPI:1255649935
Name:PORTER-FETTERMAN, ROSE MARY
Entity Type:Individual
Prefix:MRS
First Name:ROSE MARY
Middle Name:
Last Name:PORTER-FETTERMAN
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 1:20346 ENNIS RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19947-4108
Mailing Address - Country:US
Mailing Address - Phone:302-856-1926
Mailing Address - Fax:302-856-1950
Practice Address - Street 1:20346 ENNIS RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-4108
Practice Address - Country:US
Practice Address - Phone:302-856-1926
Practice Address - Fax:302-856-1950
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE51843103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool