Provider Demographics
NPI:1033306311
Name:PETROSINO, REBECCA LYNNE (PT)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:LYNNE
Last Name:PETROSINO
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 1:47 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1926
Mailing Address - Country:US
Mailing Address - Phone:860-409-4595
Mailing Address - Fax:
Practice Address - Street 1:2373 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3229
Practice Address - Country:US
Practice Address - Phone:203-659-4898
Practice Address - Fax:203-659-4899
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11695225100000X
WVPT001663225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH444881Medicare PIN
OHH444880Medicare PIN
WVQ53000AMedicare PIN