Provider Demographics
NPI:1124532601
Name:FRETTS, AIXA E (DR)
Entity type:Individual
Prefix:
First Name:AIXA
Middle Name:E
Last Name:FRETTS
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5501
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34611-5501
Mailing Address - Country:US
Mailing Address - Phone:813-570-3609
Mailing Address - Fax:
Practice Address - Street 1:2309 W. MARTIN LUTHER KING JR. BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-3360
Practice Address - Country:US
Practice Address - Phone:813-570-3609
Practice Address - Fax:813-607-2005
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5928103T00000X
FLTPPY-152103T00000X
FLIMT-4000106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR10011981Medicaid
PR10011981OtherMAPHRE, FIRST MEDICAL, HUMANA