Provider Demographics
NPI:1104157890
Name:FETTNER, MARILYN JOYCE (LCPC)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:JOYCE
Last Name:FETTNER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1963 SKYELAR CT
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-4322
Mailing Address - Country:US
Mailing Address - Phone:847-831-0079
Mailing Address - Fax:
Practice Address - Street 1:910 SKOKIE BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-4013
Practice Address - Country:US
Practice Address - Phone:847-831-0079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008430101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional