Provider Demographics
NPI:1326632779
Name:PETACCHI, MARY AMANDA (LMT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:AMANDA
Last Name:PETACCHI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 DELAWARE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-1135
Mailing Address - Country:US
Mailing Address - Phone:845-633-3866
Mailing Address - Fax:
Practice Address - Street 1:257 DELAWARE AVE STE 2
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1135
Practice Address - Country:US
Practice Address - Phone:845-633-3866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031147173C00000X, 225000000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologistGroup - Single Specialty
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Single Specialty