=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164785804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMANDA J GRETSCH, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2012
-----------------------------------------------------
Last Update Date | 06/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5402 RUFFIN RD STE 104
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92123-1319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-525-3111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 236049
-----------------------------------------------------
City | ENCINITAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92023-6049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | AMANDA GRETSCH
-----------------------------------------------------
Credential | O.T.R./L.
-----------------------------------------------------
Telephone | 760-525-3111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT6359
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------