Provider Demographics
NPI:1902023922
Name:WILCE, GRETCHEN (OTR)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:WILCE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:
Other - Last Name:VANNAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:3621 S PIMA DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-6520
Mailing Address - Country:US
Mailing Address - Phone:928-220-0723
Mailing Address - Fax:
Practice Address - Street 1:3621 S PIMA DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-6520
Practice Address - Country:US
Practice Address - Phone:928-220-0723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1041225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ504995Medicaid