Provider Demographics
NPI:1336994698
Name:FETTRELET, ISIS
Entity type:Individual
Prefix:MRS
First Name:ISIS
Middle Name:
Last Name:FETTRELET
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 1:692 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-4132
Mailing Address - Country:US
Mailing Address - Phone:786-834-1313
Mailing Address - Fax:
Practice Address - Street 1:21011 NE 25TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33180-1033
Practice Address - Country:US
Practice Address - Phone:305-988-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-20
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-312073106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician