Provider Demographics
NPI:1245613553
Name:PETKOV, RUMEN ANTONIEV (OT)
Entity Type:Individual
Prefix:
First Name:RUMEN
Middle Name:ANTONIEV
Last Name:PETKOV
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5168 W AUGUSTA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-1469
Mailing Address - Country:US
Mailing Address - Phone:651-442-5094
Mailing Address - Fax:
Practice Address - Street 1:5168 W AUGUSTA AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-1469
Practice Address - Country:US
Practice Address - Phone:651-442-5094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-007999225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
432233OtherNATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY (NBCOT)