Provider Demographics
NPI:1730497744
Name:BERETZ, TRICIA A (LIC AC)
Entity Type:Individual
Prefix:MS
First Name:TRICIA
Middle Name:A
Last Name:BERETZ
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 VINAL AVE
Mailing Address - Street 2:APT #1
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-1853
Mailing Address - Country:US
Mailing Address - Phone:617-666-5445
Mailing Address - Fax:
Practice Address - Street 1:12 ARROW ST
Practice Address - Street 2:SUITE 103
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5105
Practice Address - Country:US
Practice Address - Phone:617-767-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA238842171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist