Provider Demographics
NPI:1124365028
Name:PETRISIN, SARAH BETHANY (MSED, ATC, NCMT)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:BETHANY
Last Name:PETRISIN
Suffix:
Gender:F
Credentials:MSED, ATC, NCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7473 EISENHOWER ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2485
Mailing Address - Country:US
Mailing Address - Phone:315-591-1166
Mailing Address - Fax:
Practice Address - Street 1:7473 EISENHOWER ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2485
Practice Address - Country:US
Practice Address - Phone:315-591-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260009352255A2300X
VA0019007248225700000X
CA70569225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist