Provider Demographics
NPI:1003084757
Name:PETRICCA, DINA (PT)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:PETRICCA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 W PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-3135
Mailing Address - Country:US
Mailing Address - Phone:847-255-2348
Mailing Address - Fax:847-255-0308
Practice Address - Street 1:127 W PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-3135
Practice Address - Country:US
Practice Address - Phone:847-255-2348
Practice Address - Fax:847-255-0308
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-009748225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist