Provider Demographics
NPI:1477095800
Name:PETRILLO, STEVEN
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:PETRILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20214 NE 135TH AVE
Mailing Address - Street 2:
Mailing Address - City:WALDO
Mailing Address - State:FL
Mailing Address - Zip Code:32694-4419
Mailing Address - Country:US
Mailing Address - Phone:423-368-3807
Mailing Address - Fax:
Practice Address - Street 1:101 E STATE ST
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-3109
Practice Address - Country:US
Practice Address - Phone:610-612-5752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27083225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant