Basic Information
| Provider Information | |||||||||
| NPI: | 1174665921 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FETCH | ||||||||
| FirstName: | MONTY | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MA COUNSELING PSYCH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1850 NE LOTUS DR | ||||||||
| Address2: | APARTMENT 8 A | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413501896 | ||||||||
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| Practice Location | |||||||||
| Address1: | 63360 NW BRITTA ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977019475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413184845 | ||||||||
| FaxNumber: | 5413185156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.