Healthcare Provider Details

I. General information

NPI: 1255649935
Provider Name (Legal Business Name): MRS. ROSE MARY PORTER-FETTERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20346 ENNIS RD
GEORGETOWN DE
19947-4108
US

IV. Provider business mailing address

20346 ENNIS RD
GEORGETOWN DE
19947-4108
US

V. Phone/Fax

Practice location:
  • Phone: 302-856-1926
  • Fax: 302-856-1950
Mailing address:
  • Phone: 302-856-1926
  • Fax: 302-856-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number51843
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: