Provider Demographics
NPI:1013226075
Name:PETRA, ELECTRA (OTR)
Entity Type:Individual
Prefix:MS
First Name:ELECTRA
Middle Name:
Last Name:PETRA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2838 41ST ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103
Mailing Address - Country:US
Mailing Address - Phone:718-726-5424
Mailing Address - Fax:
Practice Address - Street 1:5030 BROADWAY
Practice Address - Street 2:SUITE 809
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1655
Practice Address - Country:US
Practice Address - Phone:212-304-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007803225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist