Provider Demographics
NPI:1821506437
Name:FETTY, EMERSON SAMUEL (SWT)
Entity Type:Individual
Prefix:
First Name:EMERSON
Middle Name:SAMUEL
Last Name:FETTY
Suffix:
Gender:M
Credentials:SWT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44481-1141
Mailing Address - Country:US
Mailing Address - Phone:330-399-6451
Mailing Address - Fax:330-394-6266
Practice Address - Street 1:150 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44481-1141
Practice Address - Country:US
Practice Address - Phone:330-399-6451
Practice Address - Fax:330-394-6266
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1610122-TRNE104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker