Provider Demographics
NPI:1770300808
Name:FETTY, MATTHEW JOHN (RBT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:FETTY
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2359 KNOLLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514-1525
Mailing Address - Country:US
Mailing Address - Phone:216-260-1405
Mailing Address - Fax:330-632-8823
Practice Address - Street 1:850 HOWLAND WILSON RD NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-2116
Practice Address - Country:US
Practice Address - Phone:216-260-1405
Practice Address - Fax:330-632-8823
Is Sole Proprietor?:No
Enumeration Date:2024-09-20
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
172V00000X
OHRBT-24-322945106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid