Basic Information
| Provider Information | |||||||||
| NPI: | 1558828996 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FETHERSON & KNIGHT PSYCHOLOGICAL SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7404 EXECUTIVE PL STE 225B | ||||||||
| Address2: | |||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207066205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2409294387 | ||||||||
| FaxNumber: | 2409294391 | ||||||||
| Practice Location | |||||||||
| Address1: | 7404 EXECUTIVE PL STE 225B | ||||||||
| Address2: | |||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207066205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2409294387 | ||||||||
| FaxNumber: | 2409294391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2019 | ||||||||
| LastUpdateDate: | 09/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | FETHERSON | ||||||||
| AuthorizedOfficialFirstName: | BIANCA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR/CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2409294387 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.