Healthcare Provider Details

I. General information

NPI: 1487052486
Provider Name (Legal Business Name): ZACHARY FETTERMAN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 11/01/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MEDICAL GROUP 4102 PINION DRIVE
USAF ACADEMY CO
80840
US

IV. Provider business mailing address

10TH MEDICAL GROUP 4102 PINION DRIVE
USAF ACADEMY CO
80840
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-5177
  • Fax:
Mailing address:
  • Phone: 179-333-5177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number10404713-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: