Healthcare Provider Details

I. General information

NPI: 1285372151
Provider Name (Legal Business Name): LAUREN NICOLE FETTIS BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2022
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 S STAPLEY DR
MESA AZ
85204-6674
US

IV. Provider business mailing address

1391 W BLUE RIDGE CT
CHANDLER AZ
85248-5509
US

V. Phone/Fax

Practice location:
  • Phone: 623-263-3966
  • Fax:
Mailing address:
  • Phone: 480-694-7301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBACB719002
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-190846
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: