Provider Demographics
NPI:1407361124
Name:PETRI, DRAGAN (OT)
Entity Type:Individual
Prefix:
First Name:DRAGAN
Middle Name:
Last Name:PETRI
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 W WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-2718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332
Practice Address - Country:US
Practice Address - Phone:956-233-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117800225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist