Provider Demographics
NPI:1083879647
Name:PETTIT BOTT, MARLENE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARLENE
Middle Name:
Last Name:PETTIT BOTT
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:W264 S7415 MT WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189
Mailing Address - Country:US
Mailing Address - Phone:262-370-1943
Mailing Address - Fax:
Practice Address - Street 1:425 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3175
Practice Address - Country:US
Practice Address - Phone:262-524-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics