Destry Allen Fritz, COTA
Individual provider Active NPI Occupational Therapy Assistant · Delavan, WI
NPI 1407068612 · NPPES record last updated Jul 8, 2007
Key facts
- NPI
- 1407068612
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Occupational Therapy Assistant 224Z00000X
- License
- 1318-027 (WI)
- Practice address
- 905 E Geneva St
Delavan, WI 53115-1922 - Phone
- (262) 728-1442
- Fax
- (262) 728-6693
- NPI assigned
- May 3, 2007
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1318-027 | WI | MD | Occupational Therapy Assistant |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Occupational Therapy Assistant | 224Z00000X | 1318-027 | WI | Yes |
Addresses
Primary practice location
905 E Geneva St
Delavan, WI 53115-1922
Mailing address
W9245 Stader Rd
Whitewater, WI 53190-4157
Phone (262) 472-0348
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 40803900 | Medicaid | WI |
Other providers in Delavan, WI
- Extendicare Homes, Inc.
- Michael J Fehling
- FMG East Geneva Street Wisconsin LLC
- Jessica Lynne Formea
- Nicholas Matthew Franz
- Furnishing Solutions
- Maria Teresa Galgano Chadha
- Javier Gallegos
- Natasha Marie Garza
- Gill Family Chiropractic
All providers in Delavan, WI · Occupational Therapy Assistant in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.