Provider Demographics
NPI:1467941138
Name:DEROBERTIS, PETRINA LOREE (LMT)
Entity Type:Individual
Prefix:
First Name:PETRINA
Middle Name:LOREE
Last Name:DEROBERTIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-1333
Mailing Address - Country:US
Mailing Address - Phone:631-903-1104
Mailing Address - Fax:
Practice Address - Street 1:1305 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2554
Practice Address - Country:US
Practice Address - Phone:631-880-3810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029913-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist