Provider Demographics
NPI:1013174051
Name:PETRO, MISTY SUSANNE (PTA,ATC,CSCS)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:SUSANNE
Last Name:PETRO
Suffix:
Gender:F
Credentials:PTA,ATC,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 W BLOOMFIELD RD STE B
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2052
Mailing Address - Country:US
Mailing Address - Phone:812-336-7910
Mailing Address - Fax:
Practice Address - Street 1:1355 W BLOOMFIELD RD STE B
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2052
Practice Address - Country:US
Practice Address - Phone:812-336-7910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99032299A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist