Provider Demographics
NPI:1245217066
Name:PETITTO, CARL ANTHONY (OT/L)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:ANTHONY
Last Name:PETITTO
Suffix:
Gender:M
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22567 SUMMIT DR BLDG 2
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-7210
Mailing Address - Country:US
Mailing Address - Phone:315-779-6784
Mailing Address - Fax:315-779-6799
Practice Address - Street 1:22567 SUMMIT DR BLDG 2
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-7210
Practice Address - Country:US
Practice Address - Phone:315-779-6784
Practice Address - Fax:315-779-6799
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0107001225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02163660OtherGROUP MEDICAID
BA0113OtherGR MEDICARE
NY02562729Medicaid
RA1322Medicare ID - Type Unspecified
BA0113OtherGR MEDICARE