Provider Demographics
NPI:1659471464
Name:FRETHIEM, CHESTER T (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CHESTER
Middle Name:T
Last Name:FRETHIEM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5648
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-5648
Mailing Address - Country:US
Mailing Address - Phone:304-920-2534
Mailing Address - Fax:
Practice Address - Street 1:12301 GRAPEFIELD RD
Practice Address - Street 2:
Practice Address - City:BASTIAN
Practice Address - State:VA
Practice Address - Zip Code:24314-4547
Practice Address - Country:US
Practice Address - Phone:276-688-4331
Practice Address - Fax:276-688-4336
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV747103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003905Medicaid
WV3810003905Medicaid
WVCP30731Medicare ID - Type Unspecified