Provider Demographics
NPI:1912377110
Name:PETREY, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:PETREY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LUTCHER
Mailing Address - State:LA
Mailing Address - Zip Code:70071-5505
Mailing Address - Country:US
Mailing Address - Phone:225-206-0992
Mailing Address - Fax:
Practice Address - Street 1:1201 S CLEARVIEW PKWY
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:LA
Practice Address - Zip Code:70121-1015
Practice Address - Country:US
Practice Address - Phone:225-206-0992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAATH.2001352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer