MEDICARE: LAURA T FETTERS MA, LPC,LAC

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
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	90	CO
2	101YP2500X	Professional Counselor	1680	CO

General Provider Information

NPI Number	:	1265498943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA T FETTERS MA, LPC,LAC

Provider Business Mailing Address
First Line	:	PO BOX 60066
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80960-0066
Country	:	US
Telephone Number	:	719-636-9126
Fax Number	:

Provider Business Practice Location Address
First Line	:	703 N TEJON ST STE C
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-1050
Country	:	US
Telephone Number	:	719-636-9126
Fax Number	:	719-636-9127

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	02/04/2021

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