Provider Demographics
NPI:1609461672
Name:BRETZKE, DONNA RAE (LMT)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:RAE
Last Name:BRETZKE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 E CAMPBELL AVE STE 11E
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-2136
Mailing Address - Country:US
Mailing Address - Phone:408-857-1333
Mailing Address - Fax:
Practice Address - Street 1:621 E CAMPBELL AVE STE 11E
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-2136
Practice Address - Country:US
Practice Address - Phone:408-857-1333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27308225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty