Provider Demographics
NPI:1821599325
Name:PETACCIA, CHRISTINE (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:PETACCIA
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 S COURTENAY PKWY APT 1379
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-4843
Mailing Address - Country:US
Mailing Address - Phone:321-298-7025
Mailing Address - Fax:
Practice Address - Street 1:137 S COURTENAY PKWY APT 1379
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-4843
Practice Address - Country:US
Practice Address - Phone:321-298-7025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00306500225X00000X
FLOT14854225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM8066OtherFL HF MEDICARE