Provider Demographics
NPI:1164900247
Name:PETRIDIS, COLLEEN (DPT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:PETRIDIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:MENARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:47 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1926
Mailing Address - Country:US
Mailing Address - Phone:860-409-4595
Mailing Address - Fax:860-409-4860
Practice Address - Street 1:43 MAIN ST UNIT H
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-2807
Practice Address - Country:US
Practice Address - Phone:860-946-0710
Practice Address - Fax:860-946-0711
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist