Basic Information
| Provider Information | |||||||||
| NPI: | 1487301495 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRITZ | ||||||||
| FirstName: | KHYLA | ||||||||
| MiddleName: | MARILYN | ||||||||
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| Credential: | COTA, BT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 FAIRVIEW PARK | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN TOP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187071312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702625924 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1081 OAK ST # 3 | ||||||||
| Address2: | |||||||||
| City: | PITTSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 186403716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887264774 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2022 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 224Z00000X | OP009993 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.