Provider Demographics
NPI:1265498943
Name:FETTERS, LAURA T (MA, LPC,LAC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:T
Last Name:FETTERS
Suffix:
Gender:F
Credentials:MA, LPC,LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60066
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80960-0066
Mailing Address - Country:US
Mailing Address - Phone:719-636-9126
Mailing Address - Fax:
Practice Address - Street 1:703 N TEJON ST STE C
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1050
Practice Address - Country:US
Practice Address - Phone:719-636-9126
Practice Address - Fax:719-636-9127
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO90101YA0400X
CO1680101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional