Provider Demographics
NPI:1376891770
Name:PETRUCCI, MARCIE LYN (COTA)
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:LYN
Last Name:PETRUCCI
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:974 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-4627
Mailing Address - Country:US
Mailing Address - Phone:203-527-7087
Mailing Address - Fax:
Practice Address - Street 1:35 BUNKER HILL RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-3304
Practice Address - Country:US
Practice Address - Phone:860-274-5428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001198224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant