Provider Demographics
NPI:1518065721
Name:LINVILLE-PETRIK, LORI ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:ANN
Last Name:LINVILLE-PETRIK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2585 MIRACLE MILE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7522
Mailing Address - Country:US
Mailing Address - Phone:928-444-8168
Mailing Address - Fax:928-444-8169
Practice Address - Street 1:2585 MIRACLE MILE
Practice Address - Street 2:SUITE 107
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7522
Practice Address - Country:US
Practice Address - Phone:928-444-8168
Practice Address - Fax:928-444-8169
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4214225100000X
NV1193225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4214OtherLICENSURE
NV1193OtherLICENSURE
AZZ141280Medicare Oscar/Certification