Provider Demographics
NPI:1750149340
Name:RICKETTS, GRETCHEN (ZUMBA, STRONG)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:RICKETTS
Suffix:
Gender:F
Credentials:ZUMBA, STRONG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21516 HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:ABITA SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70420-3906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21516 HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:ABITA SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70420-3906
Practice Address - Country:US
Practice Address - Phone:504-677-8463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer