Provider Demographics
NPI:1336569813
Name:FRESE, MARY KIENSTRA (DT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KIENSTRA
Last Name:FRESE
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2244 HENLEY ST
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-4162
Mailing Address - Country:US
Mailing Address - Phone:314-448-9169
Mailing Address - Fax:
Practice Address - Street 1:2244 HENLEY ST
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-4162
Practice Address - Country:US
Practice Address - Phone:314-448-9169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIN PROGRESS171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor