Provider Demographics
NPI:1376191908
Name:PETTIT, LORI (PTA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:PETTIT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7531 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4429
Mailing Address - Country:US
Mailing Address - Phone:262-496-6607
Mailing Address - Fax:
Practice Address - Street 1:10330 PRAIRIE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1947
Practice Address - Country:US
Practice Address - Phone:262-612-2831
Practice Address - Fax:262-612-2893
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2486-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant