Provider Demographics
NPI:1487822151
Name:PETZ, CORA
Entity Type:Individual
Prefix:
First Name:CORA
Middle Name:
Last Name:PETZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E TEAL LN
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:KS
Mailing Address - Zip Code:67025-9192
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 E TEAL LN
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:KS
Practice Address - Zip Code:67025-9192
Practice Address - Country:US
Practice Address - Phone:316-542-9973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-01638225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist