Provider Demographics
NPI:1487301495
Name:FRITZ, KHYLA MARILYN (COTA, BT)
Entity type:Individual
Prefix:
First Name:KHYLA
Middle Name:MARILYN
Last Name:FRITZ
Suffix:
Gender:F
Credentials:COTA, BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 FAIRVIEW PARK
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-1312
Mailing Address - Country:US
Mailing Address - Phone:570-262-5924
Mailing Address - Fax:
Practice Address - Street 1:1081 OAK ST # 3
Practice Address - Street 2:
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640-3716
Practice Address - Country:US
Practice Address - Phone:888-726-4774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
PAOP009993224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician