Provider Demographics
NPI:1891991360
Name:FETTIG, ELIZABETH (MSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:FETTIG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:FETTIG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:25 KESSEL CT STE 105
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-1541
Practice Address - Country:US
Practice Address - Phone:608-643-3147
Practice Address - Fax:608-643-3178
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
WI9205-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1891991360Medicaid