Provider Demographics
NPI:1629132337
Name:PETRELLA, BETHANY G (PT , MSPT)
Entity Type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:G
Last Name:PETRELLA
Suffix:
Gender:F
Credentials:PT , MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 TINKERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WILLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06279-1426
Mailing Address - Country:US
Mailing Address - Phone:860-429-0403
Mailing Address - Fax:
Practice Address - Street 1:333 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1852
Practice Address - Country:US
Practice Address - Phone:860-928-9444
Practice Address - Fax:860-928-4811
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist