Provider Demographics
NPI:1043967300
Name:PETRAITIS, RACHEL ANN
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANN
Last Name:PETRAITIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:NEW BADEN
Mailing Address - State:IL
Mailing Address - Zip Code:62265-1019
Mailing Address - Country:US
Mailing Address - Phone:618-670-7792
Mailing Address - Fax:
Practice Address - Street 1:409 W OAK ST
Practice Address - Street 2:
Practice Address - City:NEW BADEN
Practice Address - State:IL
Practice Address - Zip Code:62265-1019
Practice Address - Country:US
Practice Address - Phone:618-670-7792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.007243225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant