Provider Demographics
NPI:1700218526
Name:PETZOLD, AUDREY SUSAN (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:SUSAN
Last Name:PETZOLD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 CUCHILLA DE LUPE RD
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-8716
Mailing Address - Country:US
Mailing Address - Phone:505-867-5203
Mailing Address - Fax:
Practice Address - Street 1:32 CUCHILLA DE LUPE RD
Practice Address - Street 2:
Practice Address - City:PLACITAS
Practice Address - State:NM
Practice Address - Zip Code:87043-8716
Practice Address - Country:US
Practice Address - Phone:505-867-5203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1181225X00000X, 225XM0800X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health