Provider Demographics
NPI:1760342711
Name:FETTERMAN, EMMA RYAN
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:RYAN
Last Name:FETTERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28150 LEMOYNE RD
Mailing Address - Street 2:
Mailing Address - City:MILLBURY
Mailing Address - State:OH
Mailing Address - Zip Code:43447-9747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28150 LEMOYNE RD
Practice Address - Street 2:
Practice Address - City:MILLBURY
Practice Address - State:OH
Practice Address - Zip Code:43447-9747
Practice Address - Country:US
Practice Address - Phone:419-661-6520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-13
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLSP.03155103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool