Provider Demographics
NPI:1366176950
Name:FRETAG, MOLLY (OTD)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:FRETAG
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 GOODNIGHT TRL
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-3786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1616 E PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3238
Practice Address - Country:US
Practice Address - Phone:952-220-1669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOT-1603225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist