Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225X00000X | Occupational Therapist | 1181 | NM |
N | 225XM0800X | Mental Health | 1181 | NM |
Y | 225XP0200X | Occupational Therapist - Pediatrics | 1181 | NM |
NPI | 1700218526 |
---|---|
Provider Name | Ms. Audrey Susan Petzold |
First Address | Placitas, NM 87043-8716 |
Second Address | Placitas, NM 87043-8716 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/08/2013 |
Last Update Date | 02/08/2013 |