Provider Demographics
NPI:1972837813
Name:PETTI DANIEL, FARESA N (COTA)
Entity Type:Individual
Prefix:
First Name:FARESA
Middle Name:N
Last Name:PETTI DANIEL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:FARESA
Other - Middle Name:
Other - Last Name:PETTI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:259 MISTY GROVE DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-6623
Mailing Address - Country:US
Mailing Address - Phone:917-470-5574
Mailing Address - Fax:
Practice Address - Street 1:ALL ABOUT KIDS THERAPY SERVICE
Practice Address - Street 2:545 OLD NORCROSS ROAD
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30092
Practice Address - Country:US
Practice Address - Phone:678-377-2882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002516225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist