Provider Demographics
NPI:1114069002
Name:PETTAS, THERESA JEAN (SLP)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:JEAN
Last Name:PETTAS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3094 STEWART CT
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-4744
Mailing Address - Country:US
Mailing Address - Phone:831-384-1475
Mailing Address - Fax:
Practice Address - Street 1:919 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93906-3912
Practice Address - Country:US
Practice Address - Phone:831-754-0833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP11600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist