Provider Demographics
NPI:1003425216
Name:PETITT, MICHAEL KEITH (LMT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEITH
Last Name:PETITT
Suffix:
Gender:M
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:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:SHARPSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40374-0208
Mailing Address - Country:US
Mailing Address - Phone:606-336-0246
Mailing Address - Fax:
Practice Address - Street 1:605 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SHARPSBURG
Practice Address - State:KY
Practice Address - Zip Code:40374
Practice Address - Country:US
Practice Address - Phone:606-336-0246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY165118225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty