Provider Demographics
NPI:1801992805
Name:FETTERMAN, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:FETTERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02364-1322
Mailing Address - Country:US
Mailing Address - Phone:781-585-5574
Mailing Address - Fax:
Practice Address - Street 1:500 VICTORY RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02171-3139
Practice Address - Country:US
Practice Address - Phone:617-774-1045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1131571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical