Provider Demographics
NPI:1679612303
Name:PETRAVICIUTE, SONATA (DO)
Entity Type:Individual
Prefix:
First Name:SONATA
Middle Name:
Last Name:PETRAVICIUTE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BOND LN
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719-9619
Mailing Address - Country:US
Mailing Address - Phone:718-606-2544
Mailing Address - Fax:
Practice Address - Street 1:998 CROOKED HILL RD
Practice Address - Street 2:
Practice Address - City:WEST BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1043
Practice Address - Country:US
Practice Address - Phone:631-761-3588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2399822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry