Provider Demographics
NPI:1275540510
Name:FENTRESS, DAVID W (EDD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:W
Last Name:FENTRESS
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-6249
Mailing Address - Country:US
Mailing Address - Phone:508-993-1377
Mailing Address - Fax:508-999-7795
Practice Address - Street 1:50 N 2ND ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-6249
Practice Address - Country:US
Practice Address - Phone:508-993-1377
Practice Address - Fax:508-999-7795
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA 3487103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0514179Medicaid
MAFE-W03564Medicare ID - Type Unspecified