Provider Demographics
NPI:1194940213
Name:MAERTZ, VICKIE (OTR)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:
Last Name:MAERTZ
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 FRELSBURG RD
Mailing Address - Street 2:
Mailing Address - City:ALLEYTON
Mailing Address - State:TX
Mailing Address - Zip Code:78935-2037
Mailing Address - Country:US
Mailing Address - Phone:979-732-7021
Mailing Address - Fax:979-733-9939
Practice Address - Street 1:1370 FRELSBURG RD
Practice Address - Street 2:
Practice Address - City:ALLEYTON
Practice Address - State:TX
Practice Address - Zip Code:78935-2037
Practice Address - Country:US
Practice Address - Phone:979-732-7021
Practice Address - Fax:979-733-9939
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1110019225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0179707801Medicaid
043848583OtherEIN