Provider Demographics
NPI:1952469686
Name:PETTYJOHN, PAUL LINDSAY (OT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:LINDSAY
Last Name:PETTYJOHN
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:
Other - Last Name:MUNRO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1845 BUSINESS CENTER DR STE 127
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3434
Mailing Address - Country:US
Mailing Address - Phone:909-890-9030
Mailing Address - Fax:909-890-4393
Practice Address - Street 1:500 N CENTRAL AVE STE 850
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-3354
Practice Address - Country:US
Practice Address - Phone:818-549-9764
Practice Address - Fax:818-549-9767
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15275225X00000X
WA60315233225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA15275OtherOCCUPATIONAL THERAPY