Provider Demographics
NPI:1316586100
Name:PETTIT, LAUREL (DPT)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:PETTIT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1895 WALT WHITMAN RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3031
Mailing Address - Country:US
Mailing Address - Phone:631-577-3400
Mailing Address - Fax:
Practice Address - Street 1:1895 WALT WHITMAN RD
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3031
Practice Address - Country:US
Practice Address - Phone:631-577-3400
Practice Address - Fax:631-577-3409
Is Sole Proprietor?:No
Enumeration Date:2019-12-27
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031178225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist