Provider Demographics
NPI:1457505513
Name:PETHERICK, MICHELE JO (PT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:JO
Last Name:PETHERICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1300 FRANKLIN AVE
Mailing Address - Street 2:LL2
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-5747
Mailing Address - Country:US
Mailing Address - Phone:516-663-9099
Mailing Address - Fax:516-663-9092
Practice Address - Street 1:1300 FRANKLIN AVE
Practice Address - Street 2:LL2
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-5747
Practice Address - Country:US
Practice Address - Phone:516-663-9099
Practice Address - Fax:516-663-9092
Is Sole Proprietor?:No
Enumeration Date:2008-11-15
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY010022-12251X0800X, 2251G0304X, 2251P0200X, 2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics