Provider Demographics
NPI:1356626386
Name:PETZ, MONICA M
Entity Type:Individual
Prefix:MS
First Name:MONICA
Middle Name:M
Last Name:PETZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24492 CASTELO CIR
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5005
Mailing Address - Country:US
Mailing Address - Phone:949-951-1528
Mailing Address - Fax:
Practice Address - Street 1:24492 CASTELO CIR
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5005
Practice Address - Country:US
Practice Address - Phone:949-951-1528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2039224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2039Medicaid
CA2039Medicaid