Provider Demographics
NPI:1275686271
Name:PETITO, SHARON L (LAC, LMT)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:L
Last Name:PETITO
Suffix:
Gender:F
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3084
Mailing Address - Country:US
Mailing Address - Phone:516-695-1633
Mailing Address - Fax:
Practice Address - Street 1:1400 WANTAGH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-2257
Practice Address - Country:US
Practice Address - Phone:516-695-1633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003437171100000X
NY27022253225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist