Provider Demographics
NPI:1518325307
Name:FRICKE, RENEE (LMT)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:FRICKE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18831 SARATOGA BLVD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-7816
Mailing Address - Country:US
Mailing Address - Phone:248-210-4172
Mailing Address - Fax:
Practice Address - Street 1:18899 W 12 MILE RD STE 101
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2541
Practice Address - Country:US
Practice Address - Phone:248-210-4172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-08
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501002842225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist