Healthcare Provider Details

I. General information

NPI: 1396260097
Provider Name (Legal Business Name): TAMMY FETTER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 SUMMIT AVE
MILL VALLEY CA
94941-1001
US

IV. Provider business mailing address

370 SUMMIT AVE
MILL VALLEY CA
94941-1001
US

V. Phone/Fax

Practice location:
  • Phone: 914-393-1854
  • Fax:
Mailing address:
  • Phone: 914-393-1854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW76784
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: