MEDICARE: MARY B FETZER

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	103TC1900X	Counseling Psychologist	23840	TX

General Provider Information

NPI Number	:	1750314043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY B FETZER

Provider Business Mailing Address
First Line	:	909 FROSTWOOD DR STE 258
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77024-2309
Country	:	US
Telephone Number	:	713-465-7076
Fax Number	:	281-591-7459

Provider Business Practice Location Address
First Line	:	909 FROSTWOOD DR STE 258
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77024-2309
Country	:	US
Telephone Number	:	713-465-7076
Fax Number	:	281-591-7459

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

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	07/08/2007

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