Provider Demographics
NPI:1578014478
Name:PETRICCA, MARCELLA (DPT)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:
Last Name:PETRICCA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N LAVENTURE RD STE A
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-3901
Mailing Address - Country:US
Mailing Address - Phone:301-367-1611
Mailing Address - Fax:
Practice Address - Street 1:110 N LAVENTURE RD STE A
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-3901
Practice Address - Country:US
Practice Address - Phone:360-428-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60691189225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist