Provider Demographics
NPI:1750129466
Name:FETTERLY, SARA ANNE
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:ANNE
Last Name:FETTERLY
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 N FRANCISCO AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5488
Mailing Address - Country:US
Mailing Address - Phone:612-963-2526
Mailing Address - Fax:
Practice Address - Street 1:405 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3006
Practice Address - Country:US
Practice Address - Phone:847-441-5600
Practice Address - Fax:847-441-7968
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical