Provider Demographics
NPI:1528219433
Name:FETTERS, DENISE (PCC-SUPERVISOR)
Entity type:Individual
Prefix:MS
First Name:DENISE
Middle Name:
Last Name:FETTERS
Suffix:
Gender:F
Credentials:PCC-SUPERVISOR
Other - Prefix:MS
Other - First Name:DEEDEE
Other - Middle Name:
Other - Last Name:FETTERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PCC-SUPERVISOR
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:10470 WINESBURG RD
Mailing Address - City:MT. EATON
Mailing Address - State:OH
Mailing Address - Zip Code:44659
Mailing Address - Country:US
Mailing Address - Phone:330-927-2020
Mailing Address - Fax:
Practice Address - Street 1:10470 WINESBURG RD
Practice Address - Street 2:#265
Practice Address - City:MT. EATON
Practice Address - State:OH
Practice Address - Zip Code:44659
Practice Address - Country:US
Practice Address - Phone:330-927-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0007999-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional