Healthcare Provider Details

I. General information

NPI: 1558828996
Provider Name (Legal Business Name): FETHERSON & KNIGHT PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 09/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7404 EXECUTIVE PL STE 225B
LANHAM MD
20706-6205
US

IV. Provider business mailing address

7404 EXECUTIVE PL STE 225B
LANHAM MD
20706-6205
US

V. Phone/Fax

Practice location:
  • Phone: 240-929-4387
  • Fax: 240-929-4391
Mailing address:
  • Phone: 240-929-4387
  • Fax: 240-929-4391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. BIANCA FETHERSON
Title or Position: CLINICAL DIRECTOR/CO-OWNER
Credential: PH.D.
Phone: 240-929-4387