Provider Demographics
NPI:1679296594
Name:PETTIGREW, TARYN NICHELLE (OT)
Entity Type:Individual
Prefix:
First Name:TARYN
Middle Name:NICHELLE
Last Name:PETTIGREW
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15061 GALAPAGOS PL
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-5842
Mailing Address - Country:US
Mailing Address - Phone:703-875-1489
Mailing Address - Fax:
Practice Address - Street 1:12185 CLIPPER DR
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2236
Practice Address - Country:US
Practice Address - Phone:703-457-8648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119009818225X00000X
PAOC018708225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics