Provider Demographics
NPI:1376853689
Name:PETRALIA, PATRICIA BAXTER (OT)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:BAXTER
Last Name:PETRALIA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 WINCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-3431
Mailing Address - Country:US
Mailing Address - Phone:610-325-0262
Mailing Address - Fax:
Practice Address - Street 1:712 WINCHESTER RD
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3431
Practice Address - Country:US
Practice Address - Phone:610-325-0262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC-00077-L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist