Provider Demographics
NPI:1427623834
Name:FRITZ, KYLE JOHN
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JOHN
Last Name:FRITZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54005-3923
Mailing Address - Country:US
Mailing Address - Phone:715-607-4170
Mailing Address - Fax:
Practice Address - Street 1:734 20TH AVE
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:WI
Practice Address - Zip Code:54005-3923
Practice Address - Country:US
Practice Address - Phone:715-607-4170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5779-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant