Healthcare Provider Details

I. General information

NPI: 1659471464
Provider Name (Legal Business Name): CHESTER T. FRETHIEM PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12301 GRAPEFIELD RD
BASTIAN VA
24314-4547
US

IV. Provider business mailing address

PO BOX 5648
PRINCETON WV
24740-5648
US

V. Phone/Fax

Practice location:
  • Phone: 276-688-4331
  • Fax: 276-688-4336
Mailing address:
  • Phone: 304-920-2534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number747
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: