Healthcare Provider Details

I. General information

NPI: 1710005251
Provider Name (Legal Business Name): KATHLEEN JANE FETTER MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 PROFESSIONAL PARK DR SUITE 400
MOORESVILLE NC
28117-5599
US

IV. Provider business mailing address

127 W MARANTA RD
MOORESVILLE NC
28117-6337
US

V. Phone/Fax

Practice location:
  • Phone: 704-664-1029
  • Fax:
Mailing address:
  • Phone: 201-925-2367
  • Fax: 704-442-4162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8643
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: