Healthcare Provider Details

I. General information

NPI: 1104826247
Provider Name (Legal Business Name): VIRGINIA R FRETZ OTRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

786A N SAINT FRANCIS DR
SANTA FE NM
87501-5100
US

IV. Provider business mailing address

223 N GUADALUPE ST # 223
SANTA FE NM
87501-1850
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-2032
  • Fax: 505-984-0738
Mailing address:
  • Phone: 505-920-9969
  • Fax: 505-984-0738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1643
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: