Provider Demographics
NPI:1821071713
Name:PETITO, CYNTHIA JEAN (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:JEAN
Last Name:PETITO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 916
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32067-0916
Mailing Address - Country:US
Mailing Address - Phone:904-315-7070
Mailing Address - Fax:904-541-1413
Practice Address - Street 1:1409 KINGSLEY AVE
Practice Address - Street 2:SUITE 3A
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4537
Practice Address - Country:US
Practice Address - Phone:904-315-7070
Practice Address - Fax:904-541-1413
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT6298225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6121ZOtherMEDICARE GROUP PTAN - OT
FLU6121ZOtherMEDICARE GROUP PTAN - OT
FLU6121YMedicare PIN