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NPI Code Detail

MEDICARE: MR. MONTY JAY FETCH MA COUNSELING PSYCH

MEDICARE: MR. MONTY JAY FETCH MA COUNSELING PSYCH
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1174665921
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. MONTY JAY FETCH MA COUNSELING PSYCH
Provider Business Mailing Address
First Line : 1850 NE LOTUS DR
Second Line : APARTMENT 8 A
City : BEND
State : OR
Zip : 97701-6151
Country : US
Telephone Number : 541-350-1896
Fax Number :
Provider Business Practice Location Address
First Line : 63360 NW BRITTA ST STE 1
Second Line :
City : BEND
State : OR
Zip : 97701-9475
Country : US
Telephone Number : 541-318-4845
Fax Number : 541-318-5156
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/12/2007
Last Update Date : 07/08/2007

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