Healthcare Provider Details

I. General information

NPI: 1134424039
Provider Name (Legal Business Name): SHAMAR MARIE DAVID-FETHERSON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 01/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 PINE ST
PHILADELPHIA PA
19107-5945
US

IV. Provider business mailing address

5228 WESTFORD RD
PHILADELPHIA PA
19120-3619
US

V. Phone/Fax

Practice location:
  • Phone: 215-735-7068
  • Fax:
Mailing address:
  • Phone: 215-455-3730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: