Provider Demographics
NPI:1073546115
Name:PITALO, ANTONIA (PT)
Entity Type:Individual
Prefix:
First Name:ANTONIA
Middle Name:
Last Name:PITALO
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 1:1361 W WADE HAMPTON BLVD STE F
Mailing Address - Street 2:PMB 207
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-1146
Mailing Address - Country:US
Mailing Address - Phone:864-801-8706
Mailing Address - Fax:864-848-7203
Practice Address - Street 1:209 PATEWOOD DR
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3581
Practice Address - Country:US
Practice Address - Phone:864-272-0124
Practice Address - Fax:864-272-0129
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC452518585OtherINSURANCE PROVIDER NUMBER
SCQ340127278Medicare ID - Type UnspecifiedPROVIDER NUMBER