Provider Demographics
NPI:1689935819
Name:PETRONE, KELLY B (OT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:B
Last Name:PETRONE
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 1:69 O ST
Mailing Address - Street 2:
Mailing Address - City:SEASIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08752-1440
Mailing Address - Country:US
Mailing Address - Phone:732-266-5113
Mailing Address - Fax:
Practice Address - Street 1:69 O ST
Practice Address - Street 2:
Practice Address - City:SEASIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:08752-1440
Practice Address - Country:US
Practice Address - Phone:732-266-5113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00275500225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist