Provider Demographics
NPI:1073936498
Name:PETRY, LASHONDA (OTR/L)
Entity Type:Individual
Prefix:
First Name:LASHONDA
Middle Name:
Last Name:PETRY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4046A TRIPOLI DR
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-8015
Mailing Address - Country:US
Mailing Address - Phone:817-823-2229
Mailing Address - Fax:
Practice Address - Street 1:39180 FARWELL DR STE 211
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1015
Practice Address - Country:US
Practice Address - Phone:510-857-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT13278174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist