Provider Demographics
NPI:1164945051
Name:PETRIELLO, ANGELO (DPT)
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:
Last Name:PETRIELLO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5718
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59903-5718
Mailing Address - Country:US
Mailing Address - Phone:406-756-0134
Mailing Address - Fax:406-309-2579
Practice Address - Street 1:1275 W PUEBLO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3866
Practice Address - Country:US
Practice Address - Phone:719-542-0589
Practice Address - Fax:719-542-0119
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293255225100000X
COPTL0016672225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist