Provider Demographics
NPI:1093759334
Name:PETELICKI, MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PETELICKI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SHEPHERD DR
Mailing Address - Street 2:
Mailing Address - City:WANAQUE
Mailing Address - State:NJ
Mailing Address - Zip Code:07465-1017
Mailing Address - Country:US
Mailing Address - Phone:973-248-6216
Mailing Address - Fax:
Practice Address - Street 1:242 W PARKWAY
Practice Address - Street 2:SUITE 1
Practice Address - City:POMPTON PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07444-1029
Practice Address - Country:US
Practice Address - Phone:973-831-0717
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01023900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ066761Medicare ID - Type UnspecifiedPT