MEDICARE: MR. DANA ROBERT FETZ M.A.

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	106H00000X	Marriage & Family Therapist	MFC29024	CA

General Provider Information

NPI Number	:	1710908579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DANA ROBERT FETZ M.A.

Provider Business Mailing Address
First Line	:	3150 HILLTOP MALL RD
Second Line	:	SUITE 4
City	:	RICHMOND
State	:	CA
Zip	:	94806-1921
Country	:	US
Telephone Number	:	510-741-0721
Fax Number	:	510-758-1928

Provider Business Practice Location Address
First Line	:	3150 HILLTOP MALL RD
Second Line	:	SUITE 4
City	:	RICHMOND
State	:	CA
Zip	:	94806-1921
Country	:	US
Telephone Number	:	510-741-0721
Fax Number	:	510-758-1928

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

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	07/08/2007

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