Provider Demographics
NPI:1508637729
Name:FETZER, MARTHA (LMSW, RD, LD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:FETZER
Suffix:
Gender:F
Credentials:LMSW, RD, LD
Other - Prefix:
Other - First Name:MIMI
Other - Middle Name:
Other - Last Name:FETZER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW, RD, LD
Mailing Address - Street 1:1537 W SAINT PATRICK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-4201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 W FORT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID43638104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker