Provider Demographics
NPI:1790021228
Name:FETTIG, RENAE A (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:RENAE
Middle Name:A
Last Name:FETTIG
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:RENAE
Other - Middle Name:A
Other - Last Name:SCHATZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSOTR/L
Mailing Address - Street 1:10624 ROSE DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-9717
Mailing Address - Country:US
Mailing Address - Phone:701-226-0074
Mailing Address - Fax:
Practice Address - Street 1:1227 N 35TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-7722
Practice Address - Country:US
Practice Address - Phone:701-221-5309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1122225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1376501262Medicaid