Provider Demographics
NPI:1104826247
Name:FRETZ, VIRGINIA R (OTRN)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:R
Last Name:FRETZ
Suffix:
Gender:F
Credentials:OTRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 N GUADALUPE ST # 223
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1850
Mailing Address - Country:US
Mailing Address - Phone:505-920-9969
Mailing Address - Fax:505-984-0738
Practice Address - Street 1:786A N SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-5100
Practice Address - Country:US
Practice Address - Phone:505-984-2032
Practice Address - Fax:505-984-0738
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1643225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1643OtherSTATE OF NM REG & LIC