Provider Demographics
NPI:1205231057
Name:PETITO, JANINE
Entity Type:Individual
Prefix:
First Name:JANINE
Middle Name:
Last Name:PETITO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 ELMWOOD PARK DR APT 43
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-7519
Mailing Address - Country:US
Mailing Address - Phone:646-670-2216
Mailing Address - Fax:
Practice Address - Street 1:85 ELMWOOD PARK DR APT 43
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-7519
Practice Address - Country:US
Practice Address - Phone:646-670-2216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
333182OtherNBCOT