Basic Information
| Provider Information | |||||||||
| NPI: | 1003154691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FETHERSON | ||||||||
| FirstName: | BIANCA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7404 EXECUTIVE PL STE 225B | ||||||||
| Address2: | |||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207066205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2409294387 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7404 EXECUTIVE PL STE 225B | ||||||||
| Address2: | |||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207066205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2409294387 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2013 | ||||||||
| LastUpdateDate: | 09/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.