Provider Demographics
NPI:1174683882
Name:PETTY, ROBERT M (PTA MT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:PETTY
Suffix:
Gender:M
Credentials:PTA MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 ALBEMARLE STREET NW
Mailing Address - Street 2:SUITE 501
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016
Mailing Address - Country:US
Mailing Address - Phone:202-966-2033
Mailing Address - Fax:202-966-2034
Practice Address - Street 1:4000 ALBEMARLE STREET NW
Practice Address - Street 2:SUITE 501
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016
Practice Address - Country:US
Practice Address - Phone:202-966-2033
Practice Address - Fax:202-966-2034
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306000602225700000X
DCMT231225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist